RCRC Rower Information

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
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 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
Permission to Provide Emergency Care
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
Other Information
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