High School Registration Spring 2012

Sailor Information (One Form per Sailor)

*First Name:		*Last Name:
*Address:		*City:
*State:		*Zip:
*Parent Email:		*Child Email:
*Grade:		*High School:

Parent/Guardian Information

*Parent/Guardian Name:		*Day Phone:
*Cell Phone:
	* Address is Same as Above
Address:		City:
State:		Zip:

Medical Information

*Sailor is Under 18 18 or older

*Emergency Contact:
*Daytime Phone:
*Cell Phone:
*Medical Concerns / Known Allergies:
*Insurance Provider:

MEDICAL LIABILITY INFORMATION
                
AUTHORIZATION TO CONSENT TO TREATMENT OF A MINOR
                
As the parent or guardian of the registered sailor, I hereby authorize any x-ray examination, anesthetic, medical or surgical diagnosis or procedure supervised by any member of the medical staff or of a dentist licensed under the State Education Law and/or Public Health Law of the State and of the staff of any hospital holding a current operating certificate issued by the State Department of Health. This authorization is given in advance of any specific diagnosis, treatment or hospital care being required in order to provide authority to render care, which the aforementioned physician in his best judgment may deem advisable; and neither said agent or any organization involved assumes any financial responsibility for exercising this action. Effort shall be made to contact me before rendering treatment to the patient, but any of the above treatment will not be withheld if I cannot be reached.
                
PARENT'S CONSENT AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT
                
The parents or legal guardians (hereafter referred to in the singular) of any child or children (herein referred to as the "child"), participating in any Severn Sailing Association (SSA) program and/or junior activity (herein referred to as the "activities"), including supervised travel to local events and competitions, request that the child be allowed to participate in any of these activities. This agreement shall remain in effect until the Severn Sailing Association Junior Committee receives written notice of the cancellation of the consent or until the end of the activities described above. In return for the child being permitted to take part in the activities and to use the facilities and property of the Severn Sailing Association, each of us makes the following promises and warrants the truth of the following facts:
                
1) I am familiar with the programs included in the activities, and I understand officers and employees of the Severn Sailing Association are available to discuss the activities if I should wish additional information. I also understand I am solely responsible for the prompt arrival and departure of my child at the beginning and end of each day's activity. I will not allow my child to remain on the premises of the Severn Sailing Association after each day's program without appropriate supervision or the written permission of SSA. I agree that the Severn Sailing Association will have no responsibility for the supervision of my child at times other than during the scheduled activities. I will inform my child that he/she is expected to cooperate with, and follow the directions of, the persons in charge of the activities and to act in a manner consistent with the spirit of good sportsmanship and respect for the rights of others.
                
2) My child is in good health, and I know of no reason why he/she would be incapable of participating in the activities. My child knows how to swim. I will immediately notify the Severn Sailing Association Junior Program Director, if a change in my child's health or other condition would affect my child's ability to participate in the activities.
                
3) WAIVER OF LIABILITY I waive and release any right I, my heirs, guardians, and legal representatives may have or acquire to make a claim against, sue, attach the property of or prosecute the Severn Sailing Association and/or any of its members, directors, officers, agents, employees and affiliated organizations (herein referred to as "the releasees") for monetary damages caused by injury to my child or damage to the property of my child or myself arising from participation in the activities and use of the facilities and property of the Severn Sailing Association, whether or not the injury or damage results from the negligence or other action, except intentional acts, of any of the releasees
                
4) ASSUMPTION OF RISK I am aware that the activities may involve maneuvering a boat, sailboard or other watercraft on deep waters in potentially hazardous conditions which may include, among other things, strong wind and high waves, sudden and unexpected immersion in deep waters and collision with other watercraft or stationary objects such as docks, pilings and buoys. With knowledge of the dangers involved, I voluntarily ask that my child be allowed to take part in the activities. I ACCEPT ANY AND ALL RISKS TO MYSELF AND MY CHILD OF INJURY, DEATH AND PROPERTY DAMAGE ARISING FROM PARTICIPATION IN THE ACTIVITIES AND THE USE OF THE FACILITIES AND PROPERTY OF THE SEVERN SAILING ASSOCTION, WHETHER OR NOT CAUSED BY THE NEGLIGENCE OR OTHER ACTION, EXCEPT INTENTIONAL ACTS, OF ANY OF THE RELEASEES.
                
5) INDEMNITY AGREEMENT I agree to indemnify and hold the releasees harmless from any loss, liability, damage or cost, including reasonable attorneys fees, they may incur due to my child's participation in the activities whether or not such loss, liability, damage or cost results from the negligence or other action, except intentional acts, of any of the releases.

*I HAVE CAREFULLY READ AND AGREE TO THE ABOVE LIABILITY AGREEMENT.

Payment

You can either pay by credit card or by check. Checks may be made out to SSA Juniors. Payment is due by September 9.

Payment Method:

Please note that it may take a moment to submit the form. Please be patient.