Shen Crew WINTER 2017 Youth Registration
Online Registration form for rowers currently in grades 6 - 12
Email address *
Primary PARENT email *
This email will be the primary contact for newsletters, billing, and other information for parents. Should not be rower's email.
Your answer
LAST Name of Rower *
Your answer
FIRST Name of Rower *
Your answer
Rower Gender *
Rower Date of Birth *
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Rower School *
Enter the school which rower is currently attending
Rower Grade *
Enter the rower's current grade
Street Address of Rower *
Your answer
Zip Code of Rower *
Your answer
Parent/Guardian #1 Name *
Your answer
Parent/Guardian #1 Daytime Phone # *
Enter phone number, including area code in the following format xxx-xxx-xxxx.
Your answer
Parent/Guardian #1 Alternate Phone #
Enter phone number, including area code in the following format xxx-xxx-xxxx.
Your answer
Name of Parent/Guardian #2
Your answer
Parent/Guardian #2 Daytime Phone #
Enter phone number, including area code in the following format xxx-xxx-xxxx.
Your answer
Parent/Guardian #2 Alternate Phone #
Enter phone number, including area code in the following format xxx-xxx-xxxx.
Your answer
Rower Cell Phone #
Your answer
Rower Email
Your answer
Name of Emergency Contact #1 *
Your answer
Emergency Contact #1 Primary Phone # *
Enter phone number, including area code in the following format xxx-xxx-xxxx.
Your answer
Emergency Contact # 1 Relationship to Rower *
Your answer
Name of Emergency Contact #2 *
Your answer
Emergency Contact #2 Primary Phone # *
Enter phone number, including area code in the following format xxx-xxx-xxxx.
Your answer
Emergency Contact #2 Relationship to Rower *
Your answer
REFUND POLICY
New Rowers –A two week trial period has been provided. After that time, the rower will need to make the full or first payment. No refunds will be issued after that point.

Returning Rowers – No refund unless doctor’s note specifies the rower can no longer row. If a doctor’s note is provided, refund will be prorated: During first two weeks of practice – 75% refund.
- After 2 weeks of practice – 50% refund
- After 3 weeks of practice – 25% refund
- After 4 weeks of practice no refund

Refund Policy Agreement *
By selecting "I Acknowledge the Refund Policy" in the field below, I agree to pay the full amount even if my child is unable to finish the rowing season, unless a doctor’s note specifies the rower is physically unable to compete, in which case the fee will be prorated according to the above formula.
Required
RELEASE AND WAIVER OF LIABILITY
Friends of Shenendehowa Crew, Inc.
IN CONSIDERATION of being given the opportunity to participate in any of Friends of Shenendehowa Crew, Inc., (‘the Club”) or USRowing rowing activity (“Activity”)*, I, for myself, my personal representatives, assigns, heirs and next of kin:
1. ACKNOWLEDGE, agree or represent that I understand the nature of Rowing Activities, both on water and land based, and that I am qualified, in good health, and in proper physical condition to participate in such Activity.
2. FULLY UNDERSTAND that: (a) ROWING ACTIVITIES INVOLVE RISKS AND DANGERS of serious bodily injury, including permanent disability, paralysis and death (“Risks”); (b) these Risks and dangers may be caused by my own actions, or inactions, the actions or inactions of others participating in the Activity, the condition in which the Activity takes place, or the negligence of the Releases named below; (c) there may be other risks and social and economic losses either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COST, AND DAMAGES I incur as a result of my participation in the Activity.
3. AGREE AND WARRANT that I will examine and inspect each Activity in which I take part as a member of the Club and that, if I observe any conditions which I consider to be unacceptably hazardous or dangerous, I will notify the proper authority in charge of the Activity and will refuse to take part in the Activity until the condition has been corrected to my satisfaction.
4. HEREBY RELEASE, discharge, and covenant not to sue, the Club, their administrators, directors, agents, officers, volunteers or employees, other participating regatta organizers, any sponsors, advertisers, and if applicable, owners and lessors of premises on which the Activity takes place, (each considered on the Releasees herein) from all liability, claims, demands, losses or damages on my account caused or alleged to be caused in whole or in part by the negligence of the Releasees or otherwise, including negligent rescue operations; and I further agree that if, despite this release and waiver of liability, assumption of risk, and indemnity agreement, I, or anyone else on my behalf, makes a claim against any of the Releasees, I WILL INDEMNIFY AND SAVE AND HOLD HARMLESS each of the Releasees from any litigation’s expenses, attorney fees, loss, liability, damage, or cost which may incur as a result of such claim. I have read this agreement, fully understand its terms, understand that have given up substantial rights by signing it, and have signed it freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid, the balance, notwithstanding, shall continue in full force and effect.
Participant Waiver Acknowledgement
The participant (if age 18 or older) must read the above release and acknowledges the waiver by checking below.
PARENTAL ACKNOWLEDGEMENT
AND I, the minor’s parent and/or legal guardian, understand the nature of rowing activities and the minor’s experience and capabilities and believe the minor to be qualified to participate in such activity. I hereby release, discharge, covenant not to sue, and AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS each of the Releasees from all liability, claims, demands, losses, or damages on the minor’s account caused or alleged to be caused in whole or part by the operations, and further agree that if, despite this release, I, the minor, or anyone on the minor’s behalf makes a claim against any of the above Releasees, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS each of the Releasees from any litigation expenses, attorney fees, loss, liability, damage, or cost any may incur as the result of any such claim.
Release PARENTAL ACKNOWLEDGEMENT *
Required
CONSENT FOR TREATMENT
I (Parent or Guardian) give permission to Friends of Shenendehowa Crew, Inc., to act on my behalf for my (son, daughter) in the event of an emergency. I hereby grant permission for staff of the Friends of Shenendehowa Crew, the club advisor, or volunteer chaperones to take full responsibility and take whatever action is necessary regarding my child’s health or safety in the event I cannot be reached or in a situation where time is of the essence. I fully release Friends of Shenendehowa Crew, Inc., its staff and volunteer chaperones from any liability in connection with these decisions. I grant permission for emergency treatment by a rescue squad, emergency medical technician, private physician and /or hospital or emergency health facility staff, if needed. Any such actions will be taken in the best interests of my child and will be reported to me as soon as possible.
Parent or Guardian Consent *
Insurance Info
Insurance Company *
Your answer
Insurance Company Address *
Your answer
Insurance Policy Number *
Your answer
Name of Insured *
Your answer
Employer *
Your answer
Name of Rower's Physician *
Your answer
Rower's Physician Phone # *
Your answer
Name of Rower's Dentist *
Your answer
Rower's Dentist Phone # *
Your answer
Date of Last Medical Sports Clearance *
By a medical professional: Primary care provider, school physician/nurse. If more than 1 year from the start of practice, a new clearance needs to be performed. Please contact the registrar: in some cases, practice may need to be modified/delayed until cleared.
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Please Indicate if your child has any of the following:
Seizures *
History of Surgery *
Surgery Specifics
Please specify history of surgery if you answered Yes to History of Surgery
Your answer
Asthma *
Degree
Specify degree of infirmity, triggers if you answered yes to Asthma
Your answer
Physical Limitations *
Specifics of Limitations
Specify physical limitations if you answered Yes to Physical Limitations
Your answer
Severe Allergies *
Allergy Specifics
Specify allergies if you answered YES to Severe Allergies
Your answer
Special Dietary Needs *
Diet Specifics
Specify dietary needs if you answered Yes to Special Dietary Needs
Your answer
Other Allergies *
Other Allergies Specifics
Specify other allergies if you answered Yes to Other Allergies
Your answer
Other Special Conditions *
Specify Other Special Conditions
Your answer
Diabetes *
Tetanus Shot *
Enter Date of Last Tetanus Shot
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Medications *
Does your child take any medications?
List Medications
Specify medications if you answered Yes to Medications
Your answer
If medication is needed on a field trip the following is required: A doctor’s order and written parental permission must be on file in the health office. Self directed students who have permission to self carry may do so with the medication in the original labeled container. If the self directed student does not have permission to self carry, the teacher will need to carry the medication. Non-self directed students will need to have a parent or a nurse accompany them on the trip to administer their medication.
Will Medication be needed on any field trip? *
Field Trip: During practice or on a travel regatta.
Describe Necessary Medications
Your answer
Photo/Video Release Form
I hereby give permission for images of my child, captured during practices, regattas or other special events related to Friends of Shenendehowa Crew, Inc., activities, in video, photo and digital mediums to be used for purposes of promotional materials and publications, including posting on websites maintained by Friends of Shenendehowa Crew, Inc., and I waive any rights of compensation or ownership thereto. *
Required
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