Application for Summer Privileges


Type (Required):

Duration (Required):


Name 1: Email 1: Cell 1:

Name 2: Email 2: Cell 2:

Child/Children:

Name: Age: DOB:
Name: Age: DOB:
Name: Age: DOB:
Name: Age: DOB:

Address Summer Residence: Address Permanent Residence:
Address:
City:
State:
Zip Code:
Telephone:









Previous MIYC Summer Privilege?

(most recent year)

Sponsors

Primary Sponsor #1 Primary Sponsor #2
Name: Name:
Email: Email:

Boat Information:

Name: Length: Make: