Venice Youth Boating Association, Inc.

1330 Tarpon Center Drive, Venice, FL 34285 Phone: 941-468-1719

HandwrittenRegistration for VYBA Adventure SailingProgram 2017-2018

All sailors and sailors’ parents or guardians are requested to complete this registration form, even if a sailor has been with VYBA previously in any program and be present on

Registration Day, Saturday, August 19, 2017.

How to complete this registration form

Please print all information legibly to prevent errors when the information is placed into VYBA’s electronic records. Please do not mail it to VYBA through US Mail.

Sailor’s Information

Sailor’s Legal Last Name: ______

Sailor’s Legal First Name: ______

Sailor’s Legal Middle Name: ______

Sailor’s Nickname, if any: ______

Sailor’s Home Address: Street #, Street Name, City, Zip Code:

______

Sailor’s BirthDate (mm/dd/yyyy) ______Sailor’s Birth State ______Current age: ______

Sailor’s Gender: ☐Male ☐Female Sailor’s Social Security Number: ______

Sailor’s School Name attending now (no abbreviations please): ______

Sailor’sGrade in School for 2017-2018 school year: ______

Sailor’s email address: ______

Sailor’s Cell Phone Number: ______

Sailor’s Shirt Size:(Check one) ☐Youth Small ☐Youth Medium ☐Youth Large

☐Adult Small ☐Adult Medium ☐Adult Large ☐Adult X Large ☐Adult XX Large

List Allergies or medications or others medical conditions VYBA should know in the space below:

Continue to page 2 please

HandwrittenRegistration for VYBA Adventure SailingProgram 2017-2018 Page 2

Information required about Parents or Grandparents or Guardians of Sailors:

Father, Grandfather, or Guardian (Last Name, First Name, Middle Initial or Middle Name)

______

Please check one: ☐Father☐Grandfather ☐Guardian

Home Address: Street #, Street Name, City, State and Zip Code

______

Phone Numbers:Work: ______Home: ______Cell: ______

Phone Number in case of Emergency:______

Email Address:______

Business or ProfessionalOccupation: ______

Mother, Grandmother, or Guardian (Last Name, First Name, Middle Initial or Middle Name) Name)

Name of Mother, Grandmother, or Guardian:

Please check one: ☐Mother☐Grandmother☐Guardian

Home Address: Street #, Street Name, City, State and Zip Code

______

Phone Numbers: Work: ______Home: ______Cell: ______

PhoneNumber in case of emergency:______

Email Address:______

Business or Professional Occupation:______

In the event of an emergency involving a sailor, whom is the VYBA to call first?

Name:______Relationship to Sailor:______Phone Number:______

Name of Person submitting this Registration:_______

Please bring this completed form to our Registration Day, Saturday, August 19, 2017.

Thank you!

1