Learn To Row Membership Application Form

Rower's Address *

Parent/Guardian (1) Address *

Parent/Guardian (2) Address

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