Broad Run Crew - Learn to Row 2022
Please complete this form in order to register for Learn to Row.  The cost is $150.  Please print and sign the following waiver along with payment to
Lisa Codella
c/o Broad Run Crew
43751 Carson Court
Ashburn, VA  20147

You can find and print the waiver here:
BRC Liability Waiver: https://tinyurl.com/xn48bet4

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Rower Last Name *
Rower First Name *
Rower Email Address *
Rower Cell Phone Number
Rower Date of Birth *
MM
/
DD
/
YYYY
Rower Gender
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Rower Grade for 2022-2023 School Year *
Rower T-Shirt Size *
What is your experience level? (Novice, Experienced, Number of years) *
Parent's Name *
Parent's Email Address
Parent's Phone Number
Emergency Contact *
Emergency Contact Phone Number *
In the event of an emergency requiring medical attention, I grant permission to a physician or other hospital personnel designated by the Broad Run Crew Coaching Staff to attend my child. *
In order to participate in Broad Run Crew learn to row you must have proper and adequate medical insurance.  Please indicate that your child has medical insurance. *
Health Insurance Subscriber *
Health Insurance Company *
Does your child wear contact lenses or glasses? *
Has your child ever had any of the following? *
Yes
No
Asthma
Diabetes
Kidney Injury
Heart Condition
Allergies
EPI Pen Needed
Please List Allergies (Type N/A if none) *
Please note any other conditions that should be brought to the coaches' or a physician's attention.
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