<center>2017 Dale Jepsen One-Design Regatta Registration</center> Bellingham Yacht Club September 9-10, 2017 Contact InformationSkipper Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Enter Email Confirm Email Age MM DD YYYY Enter Birth Date. (Opti and Youth Only)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 in order to be scored.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 9/3/17 @2400 hrs. After 9/3/16 @2400 hrs. Youth Discount (All crew under 21) Single $50 $60 ($5) Double $70 $85 ($10) Triple or more $90 $105 ($15) Early Registration Type*Single Handed Boat ($50)Double Handed Boat ($70)Crewed Boat - 3 or more ($90)Late Registration Type*Single Handed Boat ($60)Double Handed Boat ($85)Crewed Boat - 3 or more ($105)Single-Handed Discount (Youth Under 21 Only)No DiscountSingle Handed Youth Discount (-$5)Double-Handed Discount (Youth Under 21 Only)No DiscountDouble Handed Youth Discount (-$10)Triple-Handed Discount (Youth Under 21 Only)No DiscountTriple Handed Youth Discount (-$15)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 South Harbor Loop Dr. Bellingham, WA 98225 ** To receive early registration prices, payment must be received by 09/3/2017 at 2400 hours.