Scituate Harbor Yacht Club

Scituate Harbor Yacht Club

Supplemental Registration Form Info

Please fill out any information that was inadvertently left off on your registration.

Participant's First Name: *

Participant's Last Name: *

Gender: *
Participant's Age: *

Membership Number: *

  (4 digits)

Medical Waiver Form
Required information for each program participant.
NOTE: We only need one copy of the medical waiver for each child. If you have already submitted one for this particular child, you can skip the fields below.

Primary Care Physician:  

Date of Birth:  

Health Insurance Card Number:  


Hospital Phone:  

Emergency Contact Name #1:  

Contact #1 Phone Numbers:  

Emergency Conctact Name #2:  

Contact #2 Phone Numbers:  

Do you have any allergies?:  
If yes, please list all allergies:  
Are any medications being taken?:  
If yes, please list all medications:  
Please list any medical conditions you feel we should be aware of:  
Please list any restrictions on physical activities:  
Additional Information/Comments:  
Acknowledgement and Release Form

I/We am/are the parents(s) or guardian(s) of the child named above, a minor child who is registered in programs at the Scituate Harbor Yacht Club.

I/We acknowledge that:

1. I/We have read and fully understand the Policies, Rules and Regulations of the SHYC.

2. I/We acknowledge and agree that there are inherent risks to personal safety in sports based activities such as sailing, tennis and swimming and that some risk remains notwithstanding all due regard for safety and the taking of proper precautions. I/We accept these risks for myself/ourselves on behalf of my child.

In consideration of the above and the admission or my/our child to programs at the SHYC, we, the undersigned, release, hold harmless, and forever discharge the Scituate Harbor Yacht Club, its employees, directors, successors and assigns, from all actions, causes of action, damages, claims and demands whatever which we have or which we, our heirs, executors, administrators, or assigns may have either independently or on behalf of our child, against the SHYC, its employees, successors and assigns, by reason of, or arising out of the participation of child named above, (a minor child) in SHYC programs, or by reason of any other cause, matter or thing whatever existing or arising during my child's participation in SHYC programs.

And further, I/We agree to indemnify SHYC, its employees, directors, successors and assigns, against all actions, damages, claims and demands which may be brought against it on behalf of my/our child in respect of or arising out of the participation of my/our child in SHYC programs and again any loss arising there from.

I/We have read over this document and understand that it is a full and final release of all claims for damages or injuries, and have read over the agreement to indemnify and understand the responsibilities which we have assumed hereunder.

Parent's Name:  

Parent's Initials:  

(by initialing here you agree to the Acknowledgement and Release statement above)
  * indicates required information

First Name: (you must leave this field blank)
Last Name: (you must leave this field blank)

© 2020 Scituate Harbor Yacht Club