Newburyport Yacht Club 300R Merrimac Street Newburyport, MA 01950         (978 ) 463-9911        VHF Channel 71

Member Departure Form

If you are leaving your slip for one night or more, kindly fill out the form below so that we are aware of your departure.

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First Name:
Last Name:
Departure Date:
Return Date:
Boat Name:
Cell Phone:
Slip Number:

The following information is not required, however, it could be useful in the case of an emergency.

General Destination:
0 /
Vehicle Make/Model/Year/Color:Vehicle 1
License Plate Number & State:Vehicle 1
Picture of vehicle 1(optional: take a picture of your vehicle and submit it with this form)
Click to take picture and attach to form

Vehicle Make/Model/Year/Color:Vehicle 2
License Plate Number & State:Vehicle 2
Picture of vehicle 2(optional: take a picture of your vehicle and submit it with this form)
Click to take picture and attach to form

Emergency Contact Information:

First Name:Emergency Contact
Last Name:Emergency Contact
Cell Phone:Emergency Contact

*Required fields.

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