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Alpena Youth Sailing Club
Complete the following form with signatures and mail to Alpena Youth Sailing Club along with payment. Payment must accompany registration. Any questions, call Pete Wilson at (989) 354 – 2175 or evenings at (989) 356 – 6420.
Student Name _______________________________________________________
Date of Birth _____________________________________________Male / Female
Parent Names _______________________________________________________
E-mail Address ______________________________________________________
Home Local
Name ______________________ ____________________________
Address _________________________ ________________________________
City/State/Zip______________________ ____________________________
Phone Numbers______________________ ____________________________
Emergency Contact Name______________________ Phone___________________
Preferred Session:
Thunder Bay River
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q 7/2,3,5,6,7
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10am-1 pm
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q 7/2,3,5,6,7
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2pm-5pm
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q 7/9-13
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10am-1 pm
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q 7/9-13
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2pm-5pm
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q 7/16-20
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10am-1 pm
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q 7/16-20
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2pm-5pm
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Grand Lake
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q 7/23-27
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11am-2 pm
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q 7/23-27
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2:45pm-5:45pm
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q 7/30-8/3
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11am-2 pm
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q 7/30-8/3
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2:45pm-5:45pm
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Alpena Youth Sailing Team q 6/12-8/2 Tuesday & Thursday 5:45pm-8:30pm
(by invitation)
Permission to Participate and Release of Liability Agreement
In consideration of accepting my child’s or my entry, I hereby, for myself and my child, waive and release any and all rights and claims for damages my child or I may have against Alpena Youth Sailing Club, Inc., its principals, directors, officers, agents, employees, volunteers, contributors, donors, their insurers, and each and every land owner, lessee, municipal and/or government agency whose property or equipment is used to conduct any activity for the Alpena Youth Sailing Club, Inc., and their insurers, if any, for any and all injuries suffered (including death) by myself or my child at any activity sponsored by these groups.
I acknowledge and understand that the sailing activity I am about to participate in or let my child participate in is an exciting and demanding challenge and it will expose us to above normal risks to injury and harm. I agree to assume responsibility for all the risks of the activity for myself and my child.
I grant permission for medical treatment to be administered to my child or myself in the event of an emergency and I assume responsibility for the expense incurred for medical attention throughout the duration of the program.
I also allow the use of my child’s or my image in any future promotional materials produced by Alpena Youth Sailing Club, Inc., for its own behalf.
List of all allergies, medications, and special needs or circumstances:
________________________________________________________________________
Parent/Guardian Signature __________________________________Date ____________
mail to:
Pete Wilson
Alpena Agency, Inc.
102 S. Third Ave.
Alpena, MI 49707
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