RCRC Rower Information

Participant Info

Rower's Information
Rower's First Name
Nehemiah
Rower's Last Name
Lerma
Preferred Name
Nehemiah
Rower's Full Mailing Address
101 Laceys Spring Dr. Laceys Spring, AL 35754
Rower's Phone
12567015615
Select Rowing Group
Middle School/Recreational
USRowing Membership Number
1541668
USRowing Membership Expiration Date
June 30, 2022
USRowing SafeSport
My rower is under 18 years of age
Rower's Birthday
07/29/2008
Rower's Age
13
Rower's Current School
homeschool
Rower's Current Grade Level
7th
Rower's Height
5'4"
Rower's Weight
100
Rower's Photo

Personal Info

Parent/Guardian(s) & Emergency Contact's Information
Parent/Guardian's Name
Rebecca Lerma
Parent/Guardian's Phone
2567015615
Parent/Guardian's Email
teamlerma8 AT gmail.com
Parent/Guardian 2 Name
Michael Lerma
Parent/Guardian 2 Phone
2567015617
Parent/Guardian 2 Email
Who should be contacted in case of an emergency?
Parent/Guardian 1, Parent/Guardian 2
Emergency Contact Name
Adonna Ryker
Emergency Contact Phone
2567012871
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
oats- he'll throw up
List any other known Medical Conditions
N/A
Rower is Physically Able to Row
Yes
Primary Care Physician's Name Name
Dr. Shane Robinson
Primary Care Physician's Number
9313634543
Medical Insurance Provider
Blue Cross
Medical Insurance Contract/ID #
NGO552A51863
Medical Insurance Policy/Group #
174022MJA8
Permission to Provide Emergency Care
Yes
Rower has completed an RCRC Swim Test
Yes
When will I Upload the Physical
Rower has turned in a physical to RCRC within the last 12 months
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 Rower or rowing family
Signature
Rebecca Lerma
Oct. 16 & 17 Regatta
Both Days
Nov 13 Regatta
Cannot Go
**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
October 4, 2021
IMAGE - upload Physical Form Page 1 of 2
IMAGE - upload Physical Form Page 2 of 2
FILE - upload Physical Form
07252103.pdf
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
07252102.pdf
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
07252101.pdf
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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