Fox Chapel Crew Club Membership Application
Personal Information:
Name of Rower _______________________________________________
US
Rowing # (if you have one)________________exp. date_______
Address __________________________________________________________________________________________________________________________
Home phone _______________
Cell #________________________
FAX# ______ ______________
Date of Birth
Age Grade Weight Height ____________
Contact Information:
Mother’s name
Father’s name________________________________________
Address _______
____________________________________________________
Home phone __________________
Work phone
__________
Rower email
Mother email
Father email _________________________________________
Please indicate the email address at
which you would like to receive parent communications
In case of emergency: please contact:
Name
Address __________
Home phone _
Work
phone ________
Relationship_____________________
Please fill out other side
Health
information:
Health Insurance Company
Policy Holder’s name __________
Policy number _______________________________
Group
number ___________________________
or
other information
Primary Care Physician ______________
Physician’ s Address ______________
Physician’ s Phone
#
__________________________
Health problems, disabilities, or
special needs
Allergies: _____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Medications:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Other Health Concerns you would like us to be aware of :