2026 PIBCSS Registration Form

2026 PIBCSS Registration

Swim Lessons | Sailing Classes | Race Team
We are looking forward to the 2026 Summer Program. Our five week program will run from 6/8/26-7/10/26. Registration Deadline: June 1, 2026.

Class Information can be found at www.pibswimsail.org/summer2026. Questions? Email pibswimsail@gmail.com.

*All participants are to fill out and bring the Code Of Conduct Form the first day of class or Sunday, June 7th Ice Cream Social.
Child Information

A separate online form must be completed for each registered child in a family.
Child Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*

MaleFemaleOther
Weight*
Height*
Grade Entering Fall 2025*
Child Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Sailing/Swimming Experience*
T-shirt Size*
Parent/Guardian Information
Name*

First NameLast Name
Home Number
Format: (000) 000-0000.
Cell Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Address (if different from participant's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact

An individual on the island in case we are unable to reach parent/guardian.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child*
Medical Information
Primary Care Provider*
Primary Care Provider Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Known Allergies*
Medical Insurance Provider*
Medical/Group Policy #
Current Medication*
Date of Last Tetanus Shot (DTaP)*
Any Medical Conditions Coaches/Instructors Need To Be Aware Of*
Emergency Medical Authorization

I, {name}, hereby authorize Put-in-Bay Community Swim & Sail (PIBCSS) to seek and obtain medical treatment for my child, {childName}, in the event of an injury or medical emergency occurring during their participation in the PIBCSS program.

In the event that I cannot be reached, I authorize PIBCSS staff or volunteers to make reasonable decisions regarding my child's care, including but not limited to administering first aid, arranging transportation to a medical facility, and consenting to medical treatment deemed necessary by qualified medical personnel.

I understand that every effort will be made to contact me or the emergency contact listed on the registration form before any medical treatment is administered. However, in situations where immediate action is required for the safety and well-being of my child, I authorize program staff to act on my behalf.

I acknowledge that swimming and sailing activities take place on open water and may involve boats, docks, changing weather conditions, and other inherent water-related risks.

I hereby release and hold harmless Put-in-Bay Community Swim & Sail, its staff, volunteers, instructors, and affiliates from liability for injuries or damages arising from my child's participation in the program, except in cases of gross negligence or willful misconduct.

I certify that my child is physically able to participate in the Swim & Sail program and has no medical conditions that would prevent safe participation.

I have read and understand this Emergency Medical Authorization and voluntarily consent to its terms.
Emergency Medical Authorization Agreement*

I AgreeI Disagree
Photo and Video Waiver

I, {name}, grant permission for Put-in-Bay Community Swim & Sail (PIBCSS) to photograph and/or video record my child, {childName}, during program activities.

I understand these images or recordings may be used for program and promotional purposes, including on PIBCSS websites, social media, newsletters, and other communications. No compensation will be provided for such use.

I release Put-in-Bay Community Swim & Sail, its staff, volunteers, and affiliates from liability related to the use of these photographs or videos.
Photo and Video Waiver Consent*

I ConsentI Do Not ConsentOther
Boat Damage Agreement

To encourage responsible care of our sailing equipment, a $100 Sailing Damage Security Deposit check (one per family, payable to PIBCSS) is required. Please bring this check to the Sunday Ice Cream Social or on the first day of class.

This deposit will only be used in the event that damage occurs due to neglect or misuse of program equipment requiring repair or replacement. Parents will be notified promptly if such an incident occurs.

At the end of the season, the deposit check will be returned to the family. Families may also choose to have the deposit designated as a tax-deductible donation to PIBCSS.
Boat Damage Agreement (you will sign for each child, but only $100/family is due)*

I AgreeI DisagreeN/A - Swimmer Only or SOS Camper
My Products*
prevnext( X )
Swim Lessons
https://www.pibswimsail.org/swimming-classes

$200.00



SOS (Start Opti Sailing)
https://www.pibswimsail.org/sos-camp

$150.00



Beginner Sailing Class
https://www.pibswimsail.org/beginner-class

$625.00



Intermediate Sailing Class
https://www.pibswimsail.org/intermediate-class

$650.00



Adventure Sailing
https://www.pibswimsail.org/adventure-sailing

$725.00



Race Team
https://www.pibswimsail.org/race-team

$950.00



Our Kids. Our Water. Our Program.
For over 75 years, PIBCSS has helped kids learn to swim, sail, and stay safe on the water.

Many families choose to add a small donation during registration to help support safety equipment, instructor training, and program resources that benefit all participants.

To learn more about donation and sponsorship opportunities, visit pibswimsail.org/support

Note: The $1.00 shown is a system placeholder and will not be charged unless you check the box and enter a donation amount. Thank you for supporting Swim & Sail!

$1.00 Donation Amount



Total

$0.00
Payment Requirement

Registration is not complete until payment is submitted. Your registration will not be finalized until payment is received. If you prefer to pay by check, please email pibswimsail@gmail.com to coordinate registration and payment before submitting this form.
Electronic Signature Agreement

BY AGREEING ABOVE AND SUBMITTING THIS FORM, I ACKNOWLEDGE THAT I AM PROVIDING AN ELECTRONIC SIGNATURE THAT IS EQUIVALENT TO AN ORIGINAL MANUAL SIGNATURE AND IS LEGALLY BINDING.
Should be Empty:

2026 PIBCSS Registration

Child Information

Parent/Guardian Information

Emergency Contact

Medical Information

Payment Requirement

Electronic Signature Agreement