RCRC Rower Information

Participant Info

: Rower's Information

Rower's First Name: Alexander

Rower's Last Name: Bennett

Preferred Name

Rower's Full Mailing Address: 2372 Old Gurley Pike New Hope AL 35760

Rower's Phone: 3038824900

Account Email: janette.t.bennett AT gmail.com

Select Rowing Group: Middle School/Recreational

USRowing Membership Number: 1559343

USRowing Membership Expiration Date: October 9, 2022

USRowing SafeSport: My rower is under 18 years of age

Rower's Birthday: 10/06/2008

Rower's Age: 13

Rower's Current School: New Hope AL

Rower's Current Grade Level: 7th

Rower's Height: 5/3

Rower's Weight: 115

Rower's Photo

Personal Info

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

Parent/Guardian's Name: Janette T Bennett

Parent/Guardian's Phone: 3038824900

Parent/Guardian's Email: janette.t.bennett AT gmail.com

Parent/Guardian 2 Name: Christopher Peterson

Parent/Guardian 2 Phone: 7066317569

Parent/Guardian 2 Email

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

Emergency Contact Name: Danna Bennett

Emergency Contact Phone: 3033783688

: Rower's Medical & Safety Information

Select Medical Conditions: None of the issues listed here

If a medical condition was selected, please explain here.: none

List known Allergies: none

List any other known Medical Conditions: none

Rower is Physically Able to Row: Yes

Primary Care Physician's Name Name: New Hope Children Clinic

Primary Care Physician's Number: 2567234673

Medical Insurance Provider: Alabama Medicaid Program

Medical Insurance Contract/ID #: 53300016337163

Medical Insurance Policy/Group #: 00

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, Agree to have completed and uploaded within 4 weeks - if at all possible, 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?: Road-side sign

Signature: Janette Bennett

Oct. 16 & 17 Regatta: Both Days

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!