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2019 CRI MILITARY SWEEPS AND COMP SCULLING ATHLETE INTAKE
We are proud to be able to offer this program with generous support from our funders, including the VA Adaptive Sports Grant Program. We ask all military participants to submit this form before the beginning of the session. All information is kept confidential and used for internal purposes only. If you have questions, please email Kirk.Hoppe@communityrowing.org. Thank you for joining the CRI Military Crew!
LAST NAME *
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FIRST NAME *
Your answer
EMAIL *
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BEST CONTACT # *
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STREET ADDRESS *
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ZIP CODE *
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DATE OF BIRTH *
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AGE *
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EMERGENCY CONTACT #1 NAME/CONTACT#/ RELATIONSHIP *
Your answer
GENDER YOU IDENTIFY WITH *
BRANCH OF SERVICE *
Required
ERA OF SERVICE *
EXAMPLE- VIETNAM OR POST 9/11
Your answer
SERVICE STATUS *
GOALS FOR PARTICIPATION *
Your answer
WHAT IS YOUR ROWING LEVEL PREFERENCE? *
PLEASE LIST 2 (OR MORE) IMPROVEMENTS YOU WOULD LIKE TO SEE REGARDING YOUR ROWING. *
Your answer
WHAT ARE YOUR HOBBIES, SPORTS, ACTIVITIES OR AREAS OF INTEREST? *
Your answer
DO YOU HAVE ANY PHYSICAL, PSYCHOLOGICAL OR SPECIAL NEEDS THAT MAY AFFECT YOUR ABILITY TO ROW OR HANDLE EQUIPMENT SAFELY? PLEASE CHECK ALL THAT APPLY. *
Required
HOW MANY DAYS A WEEK DO YOU CURRENTLY EXERCISE 30 MINUTES OR MORE? *
HAVE YOU EXPERIENCED... PLEASE CHECK ANY AND ALL THAT APPLY. *
Required
OF THE BOXES CHECKED ABOVE, HOW MANY TIMES PER WEEK DO THE SYMPTOMS OF YOUR INJURY/ DISABILITY AFFECT YOU?
DO YOU HAVE ANY ALTERATIONS IN HEARING OR VISION? *
PLEASE DESCRIBE.
Your answer
DO YOU REQUIRE ASSISTANCE GETTING INTO A BOAT OR TRANSITIONING TO A SEATED POSITION ON THE GROUND? *
Your answer
DO YOU HAVE A SERVICE CONNECTED DISABILITY? *
DO YOU HAVE ANY NEEDS OR PREFERENCES FOR LEARNING NEW INFORMATION? *
EXAMPLE- WRITTEN, VERBAL, DEMONSTRATION
Your answer
WHAT EXPECTATIONS DO YOU HAVE OF COACHES OR VOLUNTEERS? *
EXAMPLE- DRILLS EACH PRACTICE, SHOW UP ON TIME OR DEMONSTRATION OF TECHNIQUES Patience, Motivation, Positive Attitude
Your answer
IF YOU HAVE A CLASSIFIED DISABILITY, PLEASE CHOOSE A CLASSIFICATION. *
Required
PLEASE TELL US ANYTHING ELSE YOU FEEL WE NEED TO KNOW TO MAKE THIS A SAFE AND ENJOYABLE EXPERIENCE. *
EXAMPLE- I HAVE DIABETES, I AM STARTLED EASILY BY LOUD NOISES, I PREFER NOT TO BE TOUCHED. N/A
Your answer
HAVE YOU PASSED THE CRI SWIM TEST? IF NOT, YOU WILL NEED TO WEAR A LIFE JACKET. *
I UNDERSTAND THAT MY PARTICIPATION INVOLVES ROWING IN AN OPEN CRAFT IN A PHYSICALLY DEMANDING ACTIVITY WHERE THERE MAY BE UNUSUAL RISK TO MY HEALTH AND SAFETY. IN ADDITION, I UNDERSTAND THAT CERTAIN ON SHORE ACTIVITIES, SUCH AS BOAT CARRYING, MAY POSE UNUSUAL RISK TO MY HEALTH AND SAFETY. MY DECISION TO PARTICIPATE IN THIS PROGRAM IS MADE BY ME IN FULL RECOGNITION OF THESE RISKS AND IS ENTIRELY VOLUNTARY. I REPRESENT THAT I AM IN ADEQUATE PHYSICAL CONDITION TO PARTICIPATE IN THESE ACTIVITIES WITHOUT POSING A DANGER TO MY HEALTH AND SAFETY OR THE SAFETY OF OTHERS. IN CONSIDERATION OF YOUR ACCEPTANCE OF THIS APPLICATION, I HEREBY AGREE FOR MYSELF, MY EXECUTORS, ADMINISTRATORS, ADMINISTRATORS, AND ASSIGNS TO HOLD HARMLESS COMMUNITY ROWING INC., ITS DIRECTORS, OFFICERS, EMPLOYEES, REPRESENTATIVES, SUCCESSORS, AGENTS AND ASSIGNS FROM ALL LIABILITY ON ACCOUNT OF ANY INJURY OR LOSS, CLAIM OR DAMAGE TO MY HEALTH, WELL-BEING OR PROPERTY DURING MY PARTICIPATION IN THIS PROGRAM. I AGREE WITH THE TERMS OF THIS WAIVER OF LIABILITY. *
PLEASE TYPE NAME *
INDICATES ELECTRONIC SIGNATURE AS AGREEMENT TO ABOVE WAIVER
Your answer
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