Fox Chapel Crew Club Membership Application
Personal Information:
Name of Rower ______________________ _
US Rowing# (you may not have one)________________exp_______
Address_______________________________________________________________
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 :
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________