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ECSA 2017 Sailing Lesson Application
Parent/Guardian Name (Last, First)
Address
City
State (XX)
Zip Code (XXXXX)
Phone (XXX-XXX-XXXX)
Email
Student's Name (Last, First)
Age
Weight (Adult not required)
Height (X' XX")
Swimming Level
Fair
Good
Excellent
Lesson Request (Click down arrow to choose)
CR (ECSA use only)
Alternate Lesson Request (Click down arrow to choose)
Emergency Contact
Emergency Phone (XXX-XXX-XXXX)
Alt Emergency Phone (XXX-XXX-XXXX)
Person dropping off student
Person picking up student
Family physician
Medical Condition(s) limiting full participation
Student Agreement (Initial to acknowledge)
Parent Agreement (Initial to acknowledge)
Submitted by

Note:  Both the student and a parent or legal guardian must read and acknowledge the following ECSA Participation Agreement by initialing consent blocks in above application.

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