Learn To Row Membership Application Form

Rower's Information
Rower's Name *

First Name Last Name
Rower's Address *

Street Address

Street Address Line 2

City

Postal / Zip Code
Rower's Home # *

Area Code Phone Number
Rower's Cellular #

Area Code Phone Number
Rower's E-mail
Rower's School *
Birth Date *
Age *
Grade *
Gender *
Height *
Weight *
Have you rowed before *
If Yes, What Position?
What other sports do you Participate in?
Can Rower Swim? *
Please list any medical conditions or allergies that the coach should know
Parent/Guardian Information
Parent/Guardian (1) Name *

First Name Last Name
Parent/Guardian (1) Address *

Street Address

Street Address Line 2

City

Postal / Zip Code
Parent/Guardian (1) Home *

Area Code Phone Number
Parent/Guardian (1) Cellular *

Area Code Phone Number
Parent/Guardian (1) Work

Area Code Phone Number
Parent/Guardian (1) E-mail *
Parent/Guardian (2) Name

First Name Last Name
Parent/Guardian (2) Address

Street Address

Street Address Line 2

City

Postal / Zip Code
Parent/Guardian (2) Home

Area Code Phone Number
Parent/Guardian (2) Cellular

Area Code Phone Number
Parent/Guardian (2) Work

Area Code Phone Number
Parent/Guardian (2) E-mail
Emergency Contacts
Emergency Contact (1) Name *
Name
Emergency Contact (1) Phone # *

Area Code Phone Number
Emergency Contact (1) *
Relationship
Emergency Contact (2) Name *
Name
Emergency Contact (2) Phone # *

Area Code Phone Number
Emergency Contact (2) *
Relationship
Medical
In case of emergency, every attempt will be made to reach the emergency contact listed above. If no one can be reached, I give permission for the Wappingers Crew Club to seek medical attention for the above named rower.
Parent/Guardian *

First Name Last Name
If under 18, Parent or legal Guardian Signature. *

To sign signature pad, use mouse and hold down button or for touch screens use pen or finger. Clear
Policy Holder *

First Name Last Name
Insurance Company *
Policy # *
I give W.C.C. permission to use my child's picture in newspaper articles and on the W.C.C. web page.
Responsible Parent/Guardian Signature. *

To sign signature pad, use mouse and hold down button or for touch screens use pen or finger. Clear
Cost of Learn To Row Program: $100.00

Checks made payable to Wappingers Crew Club
Check #
Should be Empty:

Rower's Information

Parent/Guardian Information

Emergency Contacts

Medical