Medical Release

Rose City Rowing Club

Emergency Medical Release

Athlete's Legal Name*

First NameMiddle NameLast Name

Membership ID*

Birth date*

Date

Gender

Enter F, M, or X (non-binary)

Height*

Enter as feet and inches (e.g. 5' 6")

Weight*

Enter as pounds

Date of last Tetanus Booster*

Date

If vaccinated, please upload a copy of the athlete's COVID-19 CDC Vaccination card here.

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Allergies (include food allergies)

Dietary Restrictions (vegan, dairy free, etc.)

Learning Disability

Other Special Conditions

Current Medications

Health Insurance Carrier*

Health Insurance Policy Number*

Athlete's Physician*

Phone*

Emergency Contact (other than parent/guardian named below)*

Emergency Contact Phone*

Relationship*

In the event of accident or injury to my child or in the event of illness of my child while in, on or about the premises of Rose City Rowing Club (“RCRC”) or while participating in any activity sponsored by or under the auspices of said organization under circumstances where I am unable to consent or am not present:

1. I hereby authorize and consent to the administration of any and all medical, dental, and surgical examinations or operations and treatment or all other related care, including the administration of drugs, tests, anesthesia and/or blood transfusions to my child that may be ordered by a physician and/or dentist in attendance at the medical center deemed necessary for emergency treatment.

2. I authorize any officer, employee or volunteer of RCRC coaching, administrative or volunteer staff to consent to such medical care, attention or treatment. 3. I understand that RCRC and its officers, employees and volunteers assume no financial obligation or liability in the case on my child’s accident, injury or illness. I agree to pay the cost of such medical care, attention or treatment and to indemnify and hold harmless RCRC its officers, members, staff, volunteers, and coaches, or any other members thereof, from any and all liability for such treatment, care, or attention.

RCRC will attempt to contact me before my child is treated, but treatment will not be withheld if I cannot be reached.

Parent/Guardian(sign)*

Parent/Guardian*

Phone*

Date*

Date