Fox Chapel Crew Club
Membership Application
Personal Information:
Name of Rower
_______________________________ US
Rowing #________________exp_______
Address ___________________________________________________________ ZIP______________
Home phone ________________________ Cell #_____________________FAX# _______________
Date of Birth
Age Grade Weight Height ____________
Contact Information:
Mother’s name Father’s name_______________________
Address __ Address
________________________
_______________________________
________________________
Home phone
Home phone _______
Work phone
Work Phone
________________________
Rower email
Parent 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_____________________
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 :