Seawanhaka Corinthian Yacht Club

2017 Non-Member Application

Seawanhaka Corinthian Junior Yacht Club
314 Yacht Club Road
Oyster Bay, NY 11771

Phone: (516) 922-6200 ext.117

juniorclub@seawanhaka.org
www.seawanhaka.org

Sailor's Information

First Name *

Last Name *

Sex *

Birth Date (mm/dd/yyyy) *

Age (as of 6/26/17) *

All Known Allergies (if applicable)

How did you hear about the program? *

Parent/Guardian's Primary Contact

All non-members must have an SCYC member sponsor in order to participate in the SCJYC Junior Program. Please complete the applicable information below.

	Non Member Sponsor Information
Sponsor Name	Non Member Sponsor Information
Sponsor Member #	Non Member Sponsor Information
Relationship to Sponsor	Non Member Sponsor Information
Previously Assigned SCYC Junior Membership #	Non Member Sponsor Information

First Name *

Last Name *

Relationship to Participant: *

Mother

Father

Guardian

Other Other

Address 1 *

City *

State *

Zip *

Email Address *

Home Phone *

Mobile/Alternate Phone

Emergency Contact

Check box if Emergency Contact information is same as above

First Name

Last Name

Relationship to Participant:

Mother

Father

Guardian

Other Other

Home Phone

Mobile/Alternate Phone

Email Address

Medical Waiver

Click here for Junior Medical Waiver

Medical Waiver Acknowledgement *

I have read & acknowledged the agreement, waiver and release of the above mentioned junior medical waiver.

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Seawanhaka Corinthian Junior Yacht Club
314 Yacht Club Road

Oyster Bay, NY 11771

Phone: (516) 922-6200 ext.117

Fax: (516) 922-6203

Email: JuniorClub@seawanhaka.org

www.seawanhaka.org