PIBCSS 2024 Class Registration Form

2025 PIBCSS Registration

Swim Lessons, Sailing Camp Classes, Sailing Race Team
We are looking forward to the 2025 Summer Program. Our five week program will run from 6/9/25-7/11/25. Registration Deadline: June 1, 2025.

Class Information can be found at www.pibswimsail.org/summer2025. 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 8th 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.
Sailing/Swimming Experience*
T-shirt Size*
Parent/Guardian Information
Name*

First NameLast Name
Home Number
Cell Number*
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.
Relationship to Child*
Medical Information
Primary Care Provider*
Primary Care Provider Phone Number*
Please enter a valid phone number.
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 and Sail to seek medical treatment for my child, {childName}, in the event of an emergency during their participation in the PIBCSS program.

In the event that I am unable to be reached, I authorize the camp staff to make decisions regarding my child's medical treatment, including but not limited to administering first aid, arranging for transportation to a medical facility, and consenting to any necessary medical procedures deemed necessary by qualified medical personnel.

I understand that every effort will be made to contact me or 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 consent to the staff acting in my absence.

I hereby release Put-In-Bay Community Swim and Sail, its staff, volunteers, and affiliates from any liability for any injuries or damages that may occur during my child's participation in the program, except for those resulting from gross negligence or willful misconduct.

I certify that my child is physically capable of participating in the Swim/Sailing Camp program and has no medical conditions that would prevent them from doing so safely.

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

I AgreeI Disagree
Photo and Video Waiver

I, {name}, give permission for Put-In-Bay Community Swim and Sail to photograph and/or video record my child, {childName}, during class/race activities. These may be used for promotional purposes. I waive rights to privacy and release PIBCSS from liability related to use of these materials.
Photo and Video Waiver Consent*

I ConsentI Do Not ConsentOther
Boat Damage Agreement

To ensure 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 utilized in the event of neglect or mishandling leading to necessary repairs. Parents will promptly receive notification of any such incidents. At the season's end, the deposit will be returned, or alternatively, it can be 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
Confirmation

BY AGREEING ABOVE AND SUBMITTING THIS FORM, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT IS EQUIVALENT TO AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Class Sign Up - Copy and Paste Link for Detailed Class Information*
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Swim Lessonshttps://www.pibswimsail.org/swimming-classes
$175.00



SOS (Start Opti Sailing)https://www.pibswimsail.org/sos-camp
$150.00



Beginner Sailing Classhttps://www.pibswimsail.org/beginner-class
$625.00



Intermediate Sailing Classhttps://www.pibswimsail.org/intermediate-class
$650.00



Adventure Sailinghttps://www.pibswimsail.org/adventure-sailing
$725.00



Race Teamhttps://www.pibswimsail.org/race-team
$950.00



Make a Direct Impact on Safety This SummerFor over 75 years, PIBCSS has taught kids to swim, sail, and stay safe on the water. This year, we’ve launched our first-ever capital campaign to fund a new fleet of inflatable safety boats and invest in the long-term safety and growth of our programs. You can add a donation during registration—minimum donation: $250. Giving levels include: $250, $500, $1,000, $2,500, $5,000, and $10,000 (payment plans available at the $10,000 level). 💙 Learn more about donation levels and what your gift supports at: www.pibswimsail.org/safewaters 💙 If you know a friend, family member, or business that values youth safety on the water—please help us spread the word! Every gift, and every share, makes a difference.
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2025 PIBCSS Registration

Child Information

Parent/Guardian Information

Emergency Contact

Medical Information

Confirmation