Pleasant Bay Community Boating Online Registration

Registration

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If cost is a barrier, please contact info@pbcb.cc and we can discuss financial assistance/payment plans. Programs and prices are subject to change. We will charge a $100 non-refundable deposit per class, per student upon registering, which will be credited towards your course fees which are due in full April 1st. Refunds will be given up to May 15th minus a 10% cancellation fee. After May 15th refunds will be given if a full paying replacement is secured, minus the $100.00 deposit

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Referral Information

How did you hear about us?*

Referral Name

Year Round Mailing Address

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Additional Info

Please list someone outside of the immediate family in case of emergency *

Health Insurance Carrier*

Contact #1

Contact # 1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone *

Work #

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name*

Last Name*

Type*

How can we contact you?

Home Phone

Work #

Cell # *

Email* (Emails are kept confidential)

Confirm Email*

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)

Primary Doctor*

Immunizations YN*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)

Primary Doctor*

Immunizations YN*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)

Primary Doctor*

Immunizations YN*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)

Primary Doctor*

Immunizations YN*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)

Primary Doctor*

Immunizations YN*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Add Another Student

Required Policies

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Questions or Concerns

Comments

Payment Information

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State

Zip*

Registration

Referral Information

Year Round Mailing Address

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

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I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

Required Policies

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