2016 Dale Jepsen One-Design Regatta Registration Bellingham Yacht Club September 17-18, 2016 Contact InformationSkipper Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Email* Enter Email Confirm Email Age MM DD YYYY Enter Birth Date. (Opti and Youth)Yacht ClubYacht InformationBoat Class*29er505A-CatFormula 18 CatsFlying Junior (FJ)Flying ScotHobie 14Hobie 16Hobie 18HootLaserLaser RadialLaser 4.7LightningOpti Green (Novice)Opti White (Age Under 10)Opti Blue (Age 11-12)Opti Red (Age 13-15)Open BicRS AeroTasarVanguard 15Other ClassOther ClassSail Number*If unknown, enter "X". Sail number must be supplied to the RC prior to racing.Crew Name First Last Event WaiverIn consideration for participating in this event, I represent to its organizers that my yacht has liability insurance currently in effect, covering property damage, personal injury and death in an amount not less than $300,000 per occurrence, and that the policy covers yacht racing activities. I acknowledge that the decision to enter my yacht and crew to participate in this event is solely my own; and I agree to be bound by the International Yacht Racing Rules as adopted by US Sailing, including national prescriptions, except as modified by the organizers, and the race notice for this event. I further agree to hold harmless the Bellingham Yacht Club, its officers, representatives or race committee for damages or losses which I or anyone on my boat may incur which are associated with my participation in this event and related activities. By completing this section I accept the above statement: Full Name*Date* MM DD YYYY Parent/Guardian Approval/WaiverAs the parent or guardian of the Applicant, I agree on behalf of my child/ward to hold harmless the Bellingham Yacht Club, its Directors, Officers, Members, the Sailing Foundation, the City of Bellingham, the Instructors, or anyone else connected with this program from any claim arising from any injury my child/ward may suffer in the course of participating in this Junior Sailing Program, and I hereby authorize the Junior Sailing Program Leaders, Employees, Volunteers, Organizers, and/or other Bellingham Yacht Club personnel to sanction emergency treatment for the Applicant if none of the above persons (Parent/Guardian or Emergency Contacts) can be reached. By completing this section I accept the above statement:Parent/Guardian Full NameDate MM DD YYYY Emergency PhoneRegistrationRegistration Rates Crew Number By 9/9/16 @2400 After 9/9/16 @2400 Youth Discount (All crew under 21) Single $50 $60 ($5) Double $70 $80 ($10) Triple or more $85 $90 Early Registration Type*Single Handed Boat ($50)Double Handed Boat ($70)Crewed Boat - 3 or more ($85)Late Registration Type*Single Handed Boat ($60)Double Handed Boat ($80)Crewed Boat - 3 or more ($90)Single-Handed Discount (Youth Under 21 Only)No DiscountSingle Handed Youth Discount (-$5)Double-Handed Discount (Youth Under 21 Only)NoneDouble Handed Youth Discount (-$10)T-ShirtsT-Shirt - Small Price: $15.00 Quantity: T-Shirt - Medium Price: $15.00 Quantity: T-Shirt - Large Price: $15.00 Quantity: T-Shirt - XL Price: $15.00 Quantity: T-Shirt - XXL Price: $15.00 Quantity: Saturday Dinner TicketsSaturday dinner is included in your registration fee. You may purchase additional tickets below.Saturday Dinner Ticket Price: $10.00 Quantity: Total $0.00 PaymentPayment Method*Charge to Account (BYC Members Only)Credit Card Online via PayPalMail Check ** If mailing a check or credit card information, make check payable to "BYC" and send payment with copy of registration to: DJOD Registration Bellingham Yacht Club 2625 S. Harbor Loop Dr. Bellingham, WA 98225 ** To receive early registration prices, payment must be received by 09/16/2015 at 1700 hours. This iframe contains the logic required to handle AJAX powered Gravity Forms.