RCRC Rower Information

Participant Info

Rower's Information
Rower's First Name
Ethan
Rower's Last Name
Blackwell
Preferred Name
Ethan
Rower's Full Mailing Address
2013 Jordan Road Huntsville, AL 35811
Rower's Phone
256-2887100
Select Rowing Group
High School/Competitive
USRowing Membership Number
1503099
USRowing Membership Expiration Date
May 3, 2022
USRowing SafeSport
My rower is under 18 years of age
Rower's Birthday
04/24/2004
Rower's Age
17
Rower's Current School
Madison County High School
Rower's Current Grade Level
12
Rower's Height
6'2"
Rower's Weight
160
Rower's Photo

Personal Info

Parent/Guardian(s) & Emergency Contact's Information
Parent/Guardian's Name
Lisa Blackwell
Parent/Guardian's Phone
256-348-4664
Parent/Guardian's Email
ljblackwell AT gmail.com
Parent/Guardian 2 Name
Tim Blackwell
Parent/Guardian 2 Phone
256-348-5029
Parent/Guardian 2 Email
Who should be contacted in case of an emergency?
Parent/Guardian 1
Emergency Contact Name
Jeanne Gamble
Emergency Contact Phone
256-479-2187
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
none
List any other known Medical Conditions
none
Rower is Physically Able to Row
Yes
Primary Care Physician's Name Name
Twickenham Pediatrics
Primary Care Physician's Number
256-533-1030
Medical Insurance Provider
BC/BS
Medical Insurance Contract/ID #
PPA825104185
Medical Insurance Policy/Group #
53249
Permission to Provide Emergency Care
Yes
Rower has completed an RCRC Swim Test
Yes
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?
Radio or TV
Signature
Lisa Blackwell
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
September 9, 2021
IMAGE - upload Physical Form Page 1 of 2
IMAGE - upload Physical Form Page 2 of 2
FILE - upload Physical Form
physicaleblackwell.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
rcrc-youth-code-of-conduct-eblackwell.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
rcrc-covid-19-rules-of-conduct-contract-and-waiver-eblackwell.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