Participant Info
- Rower's Information
- Rower's First Name
- Auburne
- Rower's Last Name
- Brock
- Preferred Name
- Rower's Full Mailing Address
- 2702 Persimmon Place Hampton Cove, AL 35763
- Rower's Phone
- 256-929-5074
- Account Email
- auburnebrock AT gmail.com
- Select Rowing Group
- High School/Competitive
- USRowing Membership Number
- 1556876
- USRowing Membership Expiration Date
- August 17, 2022
- USRowing SafeSport
- My rower is under 18 years of age
- Rower's Birthday
- 04/19/2007
- Rower's Age
- 14
- Rower's Current School
- Homeschool
- Rower's Current Grade Level
- 9th
- Rower's Gender
- Female
- Rower's Height
- 5'9"
- Rower's Weight
- 135
- Rower's Photo
Personal Info
- Parent/Guardian(s) & Emergency Contact's Information
- Parent/Guardian's Name
- Amy Brock
- Parent/Guardian's Phone
- 256-929-9574
- Parent/Guardian's Email
- amy AT mbrock.com
- Parent/Guardian 2 Name
- Marcus Brock
- Parent/Guardian 2 Phone
- 256-929-9572
- Parent/Guardian 2 Email
- mbrock AT mbrock.com
- Who should be contacted in case of an emergency?
- Parent/Guardian 1, Parent/Guardian 2
- Emergency Contact Name
- Anna Cunningham
- Emergency Contact Phone
- 423-432-1452
- Rower's Medical & Safety Information
- Select Medical Conditions
- None of the issues listed here
- If a medical condition was selected, please explain here.
- List known Allergies
- Seasonal, food sensitivity to Banana & Avocado
- List any other known Medical Conditions
- N/A
- Rower is Physically Able to Row
- Yes
- Primary Care Physician's Name Name
- James Morrison
- Primary Care Physician's Number
- 256-265-0350
- Medical Insurance Provider
- BC Anthem
- Medical Insurance Contract/ID #
- SAC797A16392
- Medical Insurance Policy/Group #
- 174147M8A1
- Can rower tread water for 10 minutes?
- Yes
- Rower has completed an RCRC Swim Test
- No
- When will I Upload the Physical
- Rower has completed physical and will or has uploaded the form
- RCRC WAIVERS
- RCRC Waivers: Please read and check the boxes to agree to the following waivers below: Participation Waiver, Liability Relating to Coronavirus/COVID-19 Waiver, Carpool Release, & Youth Media Release.
- Participation Waiver
- Yes
- Waiver of Liability COVID-19
- Yes
- Carpool Release Agreement
- Yes
- Youth Media Release Agreement
- Yes
- Payment Options
- Credit Card
- Rower's T-Shirt Size
- M
- Where did you hear about RCRC's Rowing Program?
- RCRC Website
- Signature
- Amy Brock
- Oct. 16 & 17 Regatta
- Both Days
- Nov 13 Regatta
- Attend
- **WHAT TO DO IF YOU SELECT THE WRONG IMAGE/FILE WHEN UPLOADING**
- Once you select an image/file to upload, you have to save it before you can change it. Ex. You select an image of the physical's 2nd page where the 1st page should be: click save - delete it - and attach it in the right place.
- Provide the date the physical was performed (on the physical) & Upload both pages of your physical as either: Two images - one of each page (jpeg preferred) or One document (pdf preferred) with both pages.
- Date Physical Was Performed
- August 22, 0021
- IMAGE - upload Physical Form Page 1 of 2
- IMAGE - upload Physical Form Page 2 of 2
- FILE - upload Physical Form
- Upload the signed page of the Youth Conduct as either an image or file & Upload the COVID-19 Rules of Conduct Contract as either: Two images - one of each page or One document with both pages. (jpeg & pdf preferred)
- IMAGE - upload Youth Conduct Code Page 1 of 1
- FILE - upload Youth Conduct Code
- IMAGE - upload COVID-19 Rules of Conduct Contract Page 1 of 2
- IMAGE - upload COVID-19 Rules of Conduct Contract Page 2 of 2
- FILE - upload COVID-19 Rules of Conduct Contract
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- Help RCRC Out: After you upload a form, check the corresponding box below. This will help us keep track that each rower has uploaded all the documents needed to finish the registration process. Thanks!
- I have completed my forms!
- Physical, Youth Conduct Code, COVID-19 Waiver