Takapuna Grammar Rowing Club - 2019/20 Registration & Health Profile
Version: 26 Jun 19
Email address *
This form must be completed by the Parent/Guardian(s) of the Crew Member (a separate form is to be completed for each Crew Member). Please note that each Crew Member is to also complete a separate 'Crew Member Declaration'.
If you have any questions regarding the form please contact the Club Secretary (secretary@tgsrowing.org.nz)
CREW MEMBER DETAILS
Crew Member First Name *
Your answer
Crew Member Last Name *
Your answer
Crew Member Gender *
Crew Member Date of Birth *
MM
/
DD
/
YYYY
Crew Member's School Year Level (in 2019) *
Crew Member's Mobile Number (or best number to contact crew member) *
Your answer
Crew Member's Email Address *
Your answer
Crew Member's Home Address (for International Student, please use your Host's address) *
Your answer
International Student *
PARENT/GUARDIAN DETAILS
Parent/Guardian 1: First Name *
Your answer
Parent/Guardian 1: Last Name *
Your answer
Parent/Guardian 1: Mobile Number *
Your answer
Parent/Guardian 1: Email Address *
Your answer
Parent/Guardian 2 (if applicable): First Name
Your answer
Parent/Guardian 2 (if applicable): Last Name
Your answer
Parent/Guardian 2: Mobile Number
Your answer
Parent/Guardian 2: Email Address
Your answer
If 2nd Parent/Guardian is not listed/applicable, please advise alternative contact (for emergency purposes):
Alternative Contact First Name
Your answer
Alternative Contact Surname
Your answer
Alternative Contact Mobile Number
Your answer
EMAIL COMMUNICATIONS
As a default we will ensure that any parent/guardian that is listed above is included in our group email list. If you have any additional email addresses (eg another parent/caregiver/host family etc) that you would like to have added to the list, please complete the following question.
Additional Email Address(es) to be added to our Group Email (if applicable):
Your answer
2019/20 FEE SCHEDULE
For International fee schedule and any other questions regarding fees or to confirm which Squad your Crew Member will be commencing the season in, please contact our Club Secretary (secretary@tgsrowing.org.nz).

For Development Squad crew members, Parent/Guardian will be consulted prior to any crew member being invited to move into the Competition Squad as there will be an increase in fees.
Fees payable for above named Crew Member (please click one box only)
Development Squad
Competition Squad
Coxswain
International Student
1st Crew Member Fee
2nd Crew Member Fee
CREW MEMBER MEDICAL, HEALTH & SAFETY AND DIETARY INFORMATION
Please check box if the Crew Member has any of the following medical conditions: *
Yes
No
Migraine
Epilepsy
Asthma
Diabetes
Travel Sickness
Heart Condition
Sleep Walking
Colour Blindness
Fits of any type
Chronic nose bleeds
Dizzy spells
If 'yes' to any of the above questions re medical conditions, please provide further details as you deem necessary (we may also contact you to discuss further)
Your answer
Is the Crew Member currently taking any medication? *
If yes (to above question re current medication) please provide details
Your answer
Please advise Crew Member's Medic Alert Bracelet number (if applicable)
Your answer
Date (year) of last Tetnus injection *
Your answer
Please outline any major injuries (breaks, strains etc) or illness (glandular fever etc) in the last six months that may limit the Crew Member fully participating in training and competition
Your answer
Does the Crew Member have any allergies to: *
Yes
No
Prescription Medication
Food
Insect Bites/Stings
Other
If you answered yes to any of the above questions regarding allergies, please provide details (we may also contact you to discuss further)
Your answer
Please provide any information that the club and coaches should be aware of to ensure the physical and emotional safety of the Crew Member? (eg cultural practices; disability; anxiety about heights/darkness/small spaces; pregnancy; behaviour or emotional problems etc). We may contact you to discuss further.
Your answer
What pain/flu medication may the Crew Member be given if necessary (eg paracetamol, ibuprofen etc) *
Your answer
Dietary requirements: *
Required
TERMS & CONDITIONS AND PERMISSIONS
By filling out this registration form and checking the boxes in the Terms & Conditions below I/we (parent/legal guardian(s) named below) agree and give permission for the following:
Terms and Conditions/Permissions: *
I accept
I do not accept
I give permission for the above named Crew Member to join Takapuna Grammar School Rowing Club and to take part in all activities planned within the season.
I agree to pay all costs, and understand that they are non-refundable.
I certify that the above named Crew Member is capable of swimming 50m unaided.
I will inform the Rowing Club as soon as possible of any changes in the medical or other circumstances throughout the season.
I give approval for photographs to be taken of the above named Crew Member and understand that these photos may be posted to social media or utilised by the Rowing Club for publicity purposes.
I give permission for the above named Crew Member to travel (and be accommodated) with the club where required for training events, camps and regattas
I agree to the above named Crew Member receiving any emergency medical, dental, or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present.
I agree to pay any medical costs, incurred by the above named Crew Member, not covered by ACC or a Community Services card.
I understand that a condition of the above named crew member being allowed to attend camps and regattas is high standards of attendance and behaviour at both Takapuna Grammar School Rowing Club and Takapuna Grammar School. I also understand that if my son/daughter does not meet these standards that any payment incurred will not be refunded.
I understand that if the above named Crew Member is involved in a serious disciplinary problem, including the use of illegal substances and/or alcohol or actions that threaten the safety of others, she/he may be sent home at my expense.
I am willing to comply with requests of the club and will follow the Health and Safety procedures they have set.
I am willing to volunteer to assist at training, regatta and fundraising events as requested by Takapuna Grammar School Rowing Club.
I will comply with the clubs and school's expectations, policies and procedures in relation to the supervision of students and will act in a professional and socially responsible way when supervising and interacting with crew members.
I agree that there is no place for alcohol/drugs at a school event.
Parent/Guardian 1 (name): *
Your answer
Relationship of Parent/Guardian 1 to Crew Member: *
Your answer
Parent/Guardian 2 (name) - if applicable:
Your answer
Relationship of Parent/Guardian 2 to Crew Member (if applicable):
Your answer
A copy of your responses will be emailed to the address you provided.
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