Mobility Cup 2005

Get On Board!!

This form is for a MC2005 competitor. IT IS NO LONGER USED. DO NOT SUBMIT.

Please read the Notice of Race page before starting to complete your registration.

The Sailing Companion Form may be found here.

If you have any questions or need to update your registration once you have submitted it,
please contact the DSA-A Business Manager.

Note : This is a fairly long form. Please fill in all the fields that apply to you.
Mandatory fields are marked with *.

Personal Information

First Name*

Last Name*

Address*

Address 2

City*

Province/State*

Country*

Postal Code/Zip*

email Address*

Please include your area code and or country code with all phone or fax numbers.

Home Phone*

Work Phone

ext.

Cellular Phone

Fax

Gender

Male Female

Birth Year

Preferred Language

English French

Assistance Requirements

Wheelchair/Mobility Aids
(Please describe in detail)

Care Giver Information

Will you be accompanied by a care giver?
Yes   No
Will this person also be your sailing companion?
Yes   No
If you answered "yes" to the above question, please complete the sailing companion registration form as well.
* Will you need the services of an attendant while in Calgary? Yes   No

Other Special Needs (Please describe in detail)

Boat Transfer Assistance

* Can you transfer in and out of the boat yourself?
Yes   No
* Do you require some manual help?
Yes   No
Do you require the use of a lift (hoist)?
Yes   No

Other Transfer Requirements (Please describe in detail)

Assistance Devices

Can you bring your own sling for the lift?
Yes No N/A

I will be bringing these other assistive devices (Please describe)

Medical and Health Information

Health Plan Number

Other Medical Plan Number

Doctor's Name

Emergency Contact Name *

Emergency Contact Number *

Nature of your disability (Please describe in detail)

How long have you had your disability?

First Aid or Personal Care Instructions

Medications and Allergy Information

Do you wear contact lenses?

Yes No

A Release and Waiver of Liability must be executed by each competitor (or guardian) and submitted to the MC2005 Registrar in order to complete registration, no later than 10:00 Saturday August 22, 2005.

To confirm that you understand this requirement, please type the words
" I understand and agree with this requirement " in the box below. * (required field)

Travel Information

If you need assistance with your travel arrangements, please, email the DSA-A Business Manager.

Travel to Calgary

Arrival Date	Via/By	Own Vehicle Yes No
Air Arr. Time	Train Arr. Time	Bus Arr. Time
Airport Pick-Up Request Yes No

Travel From Calgary

Departure Date	Via/By	Own Vehicle Yes No
Air Departure Time	Train Departure Time	Bus Departure Time
Airport Drop-Off Request Yes No

Local Transportation will be arranged by means of accessible buses.

Accommodation Information

I am a local Competitor and am prepared to offer a billet to an out-of-town competitor.
Yes No

I will be staying at

Hotel/Motel/Other Name

Phone Number

Number of others in your party

Banquet Information

Each competitor is entitled to a single Banquet ticket at no additional cost. A Competitor who requires an attendant can purchase one additional Banquet ticket at the reduced rate of $15. While space is limited for the Banquet, further additional tickets may be available (at a higher cost) at the regatta, depending on available space.

I would like a banquet ticket Yes No

I would like an extra banquet ticket Yes No

Boat Information

All competitors must ensure that their boat has Liability Insurance coverage in the amount of at least $1 Million CDN. All competitors must also supply a refundable Damage Deposit of $200 CDN along with their registration.

See the Notice of Race for other information pertaining to boats.

I will bring my own Martin 16 * Yes No

Boat Ownership

Sail Number

Hull Number

Owner's Name

Owner's Address

Owner's Phone Number

Boat's Insurance Company

Policy Number

Boat Transportation to MC2005 (Please provide details)

Describe equipment that you will be bringing with your boat.

Boat Charter Request

I wish to charter a Martin 16 Yes No

Tell us about your sailing experience *
note: experience not necessary to charter a boat

I plan to compete in the following fleet: Gold Silver

Thank You

Mobility Cup is usually over-subscribed. This form does not guarantee your participation in Mobility Cup 2005. We must receive your entry fee, damage deposit and a completed Release and Waiver of Liability to complete your registration. Completion before June 30, 2005 will enhance your chances of inclusion.

If you have requested an M16 Charter from the MC2005 Organizing Authority, confirmation and assignment of charter boats will be on or about June 30, 2005.

Entry fee is CDN $150.00. (CDN $175.00 after July 31, 2005)

If you have submitted this form through the Mobility Cup 2005 Web site, you will receive an email giving you method of payment options.

If you are mailing this form, please include a cheque payable to
Mobility Cup 2005 and mail to:

DSA-Alberta - Mobility Cup 2005
Suite 500,
11012 Macleod Tr. S.
Calgary, Alberta T2J 6A5

I'd like someone to follow-up with me about...

If you have any questions or need to update your registration once you have submitted it, please e-mail DSA-A Business Manager.