Name of Junior Sailor’s Club or Association PEQUOT YACHT CLUB

2007 WAIVER AGREEMENT

Junior Sailor ______Parent /Guardian ______

Please Print Please Print

The undersigned is the Parent/Guardian of the Junior Sailor named above and hereby acknowledges that the execution of this Agreement is a condition to the participation of the Junior Sailor in his/her own Junior Sailing Program (hereinafter referred to as the “Program”) as stated above. The undersigned accepts that the sport of sailing and the conduct of the Program entail and are subject to certain inherent risks, and, on behalf of the Junior Sailor, accepts all risks on land and at sea of participation in the Program. Now, therefore, the undersigned does hereby agree as follows:

1)The undersigned consents to the participation of the Junior Sailor in the Program and agrees that this will extend to the PEQUOT YACHT CLUB.

(name of junior sailor’s club/assoc. as stated above)

2)The undersigned consents to the participation of the Junior Sailor in all regattas, clinics, and sailing events (hereinafter collectively referred to as “Regattas”) which are a part of the Program and acknowledges that said consent is without exception within the limits proscribed within, unless a specific exception is noted herein. The undersigned further agrees that this Agreement will extend to the benefit of yacht clubs/ sailing associations (hereinafter referred to as “Host Clubs”), which are the host to or venue of such Regattas, and to the Junior Sailing Association of Long Island Sound, Inc. (hereinafter referred to as “JSA”). The list of Host Clubs is listed on the back. The undersigned further acknowledges that Parent/Guardian has reviewed the JSA 2007 Schedule prior to the execution of this document and further understands that changes to the schedule, including but not limited to changes of venues, may be made at any time. The up-to-date Regatta schedule is published at the JSA web site If exceptions are desired please enter the names of the regattas or host club(s) to which consent is not given ______

3)The undersigned waives any claims against and releases any obligation of the Club, each Host Club, the JSA and all of their respective members, employees, agents and all persons serving as members of the Race Committees or Juries or any other person acting in any capacity for the conduct of the program or any Regatta in relation to any loss, injury or damage, on land or at sea, to the Junior Sailor or to the boat or other property of the undersigned or the Junior Sailor to the fullest extent permitted by law.

4)The undersigned agrees to reimburse the Club, any Host Club, the JSA and all of their respective members, employees, agents and all persons serving as members of the Race Committees or Juries or any other person acting in any capacity for the conduct of the Program or any Regatta for any loss or damage to property, and hold the Club, each Host Club and the JSA harmless from any claim, loss or injury caused by the negligence, or misconduct of, or failure to exercise reasonable care by the Junior Sailor.

I have thoroughly read and understand the 2007 Waiver Agreement and have reviewed the 2007 JSA schedule. By signing this document, I acknowledge the execution of this agreement and agree to each of the provisions listed above.

Signature of Parent/Guardian ______Dated ______

PARTICIPANT & MEDICAL INFORMATION

Home Address ______City ______ST______ZIP ______

Home Phone (_____)______FAX (_____)______e-mail ______

Summer Phone (if different) (_____)______Date of birth ______MALE / FEMALE

Mother’s name ______Father’s name ______

Mother’s work phone (______)______home (_____)______cell (______)______

Father’s work phone (______)______home (_____)______cell (______)______

Physician ______Phone (______)______Name of insured ______

Insurance co. ______Policy # ______Group # ______

Chronic illness, medical conditions, allergies or medication being taken (Please list, or write none)

MEDICAL AUTHORIZATION

I hereby authorize an instructor from my Club or Program, or an adult who bears this document, to authorize emergency treatment for the Junior Sailor named above in the event that a parent or legal guardian cannot be reached at the above telephone numbers at the time of the emergency.

Signature of Parent/Guardian ______Dated ______

** EMERGENCY CONTACTS IF PARENTS CANNOT BE REACHED:

______(_____)______(_____)______

______(_____)______(_____)______

Name Home Phone Work Phone Relationship to sailor

Junior Sailor______Junior Sailor’s Club/Association PEQUOT YACHT CLUB

SAILING INFORMATION 2007

CLUB PHONE (203) 255-5740 JR. PHONE (203) 255-5740 ext. 21

HEAD INSTRUCTOR Amanda Lyall

√CHECK ALL THAT APPLY:√CHECK ALL THAT APPLY AND PROVIDE

CLASS / CLASSES FOR 2007MEMBERSHIP # WHERE APPLICABLE:

OPTIMISTJSA MEMBER

BLUE JAYUS SAILING MEMBER #______

PIXELOPTIMIST CLASS MEMBER

LASER RADIALBLUE JAY CLASS MEMBER

LASER STANDARDPIXEL CLASS MEMBER

CLUB 420LASER CLASS MEMBER

CLUB 420 CLASS MEMBER

BOATS TO BE SAILED IN 2007 SEASON:

BOAT #1 CLASS ______SAIL #______NAME ______HULL COLOR ______

BOAT #2 CLASS ______SAIL #______NAME ______HULL COLOR ______

Host Clubs

Revised: 11/30/06ar

American Yacht Club

Beach Point Yacht Club

Belle Haven Yacht Club

Black Rock Yacht Club

Cedar Point Yacht Club

Centerport Yacht Club

Cold Spring Harbor Beach Club

Darien Junior Sailing

Devon Yacht Club

Douglaston Yacht Club

Head of the Bay Club

Hempstead Harbor Club

Horseshoe Harbor Yacht Club

Housatonic Boat Club

Huguenot Yacht Club

Huntington Yacht Club

Indian Harbor Yacht Club

Knickerbocker Yacht Club

Larchmont Shore Club

Larchmont Yacht Club

Lloyd Neck Bath Club

Manhasset Bay Yacht Club

Milford Yacht Club

New York Yacht Club

Noroton Yacht Club

Northport Bay Sailing Assoc.

Northport Yacht Club

Norwalk Yacht Club

Orient Yacht Club

Orienta Beach Club

Pequot Yacht Club

Port Washington Yacht Club

Riverside Yacht Club

Rocky Point Club

Roton Point Sailing Association

Sagamore Yacht Club

Sea Cliff Yacht Club

Seawanhaka Corinthian Y. C.

Shelter Island Yacht Club

Shore & Country Club

Southampton Yacht Club

Sprite Island Yacht Club

Stamford Yacht Club

Stuyvesant Yacht Club

Tokeneke Beach Club

Waterfront Center

Wee Burn Country Club

Other Venues:

US Merchant Marine Academy

SUNY Maritime College

Revised: 11/30/06ar

For the up-to-date 2007 Regatta schedule,

see the Junior Sailing Association of Long Island Sound web site

Revised: 12/11/05ar