Learn To Row Membership Application Form

Rower's Information
T-shirt size (Adult sizes)
S, M, L, XL, XXL
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 *
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
Policy # *
Insurance Company *
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: $150.00

Payment Options:

1. Venmo the payment to @wappingers-crew-club

2. Checks made payable to Wappingers Crew Club

PO Box 221 Hopewell Junction, NY 12533
Please select ALL shifts you can attend for Learn to Row. Athletes will be assigned to 2 shifts based on availability. If you can't attend a specific shift, please don't select it. We will accommodate preferences on a first come first serve basis. Because of equipment restrictions we need all shifts be evenly filled. Session begins September 21st and ends October 30th with cleanup day to be announced.

Tuesday 5:00pm - 6:30pm Saturday 9am - 10:30am Saturday 10:30am - 12pm
Should be Empty:

Rower's Information

Parent/Guardian Information

Emergency Contacts

Medical