Burlington Able Sail
841 LaSalle Park Road
Burlington, ON L7T 4G6

Charitable Registration - 84584 8100 RR0001

Registration Form for Sailing Instructions for
Individuals with Physical and Cognitive Challenges

Title

First Name*

Last Name*

Address*

Address 2

City*

State/Province*

Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip/Postal Code*

Phone*

Email Address*

Confirm Email Address*

Gender*

Male

Female

Other

Age*

Sailing Experience*

Do you need a lift transfer?*

yes

no

Do you require a companion sailor?*

yes

no

don't know

Can you sail solo?*

yes

no

don't know

Sailing skills*

none

recreational

competitive

What are your medical conditions?*

What special needs do you have?*

Are you diabetic?*

yes

no

Do you have seizures?*

yes

no

Are there any other issues we should be aware of?

Desired day of the week?*

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred time? (9:00am - 4:00pm)*

Second option for day?*

Tuesday

Wednesday

Thursday

Second option preferred time? (9:00am - 4:00pm)*

Emergency Contact Name*

Emergency Contact Phone Number*

Enter the code displayed*