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
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
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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!