RCRC Rower Information

Participant Info

: Rower's Information

Rower's First Name: George

Rower's Last Name: Dill

Preferred Name: George

Rower's Full Mailing Address: 3107 Haver Hill Ln SE

Rower's Phone: 256-426-8293

Account Email: Nikkimdill AT gmail.com

Select Rowing Group: High School/Competitive

USRowing Membership Number: 1467308

USRowing Membership Expiration Date: September 20, 2022

USRowing SafeSport: My rower is under 18 years of age

Rower's Birthday: 10/03/2005

Rower's Age: 15

Rower's Current School: Lee High School

Rower's Current Grade Level: 10

Rower's Height: 6’2”

Rower's Weight: 240

Rower's Photo

Personal Info

: Parent/Guardian(s) & Emergency Contact's Information

Parent/Guardian's Name: Nicole Dill

Parent/Guardian's Phone: 256-426-8293

Parent/Guardian's Email: Nikkimdill AT gmail.com

Parent/Guardian 2 Name: Drew Dill

Parent/Guardian 2 Phone: 256-714-8393

Parent/Guardian 2 Email: Ddill AT wilmerlee.com

Who should be contacted in case of an emergency?: Parent/Guardian 1

Emergency Contact Name: Dianne Dill

Emergency Contact Phone: 257-652-3390

: Rower's Medical & Safety Information

Select Medical Conditions: Rower has asthma

If a medical condition was selected, please explain here.: Mild exercise induced asthma. Inhaler may rarely be needed

List known Allergies: Seasonal

List any other known Medical Conditions: ADHD

Rower is Physically Able to Row: Yes

Primary Care Physician's Name Name: Kathryn Montgomery

Primary Care Physician's Number: 256-424-8200

Medical Insurance Provider: BCBS of AL

Medical Insurance Contract/ID #: Ppa817360839

Medical Insurance Policy/Group #: 19643

Permission to Provide Emergency Care: Yes

Rower has completed an RCRC Swim Test: Yes

When will I Upload the Physical: Agree to have completed and uploaded within 4 weeks - if at all possible

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: Nicole Dill

Oct. 16 & 17 Regatta

Nov 13 Regatta

**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

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

---------->: 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!