Takapuna Grammar Rowing Club Learn to Row 2019 Registration & Health Profile
Version: 21 May 19
Email address *
Student's Surname *
Your answer
Student's first name *
Your answer
Student's School *
Your answer
Student Date of Birth *
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/
DD
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YYYY
Please check box if the student/participant has any of the following medical conditions:
Please advise child's Medic Alert Bracelet number (if applicable)
Your answer
Is the student currently taking any medication? *
If yes (to above question) please provide details below:
Your answer
Is there any information the staff should know to ensure the physical and emotional safety of the student? (for example cultural practices; disability; anxiety about heights/darkness/small spaces; pregnancy; behaviour or emotional problems etc). *
If yes (to above question) please provide further info (either below or via separate correspondence)
Your answer
Terms & Conditions
By filling out this registration form and checking the box below I (parent/legal guardian) agree and give permission for the following:

* I give permission for the below named Student to take part in this activity.
* I certify that the below named Student 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 between now and the commencement of the Learn to Row Programme.
* I agree to the student receiving any emergency medical, dental, or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present.
* Any medical costs not covered by ACC or a Community Services card will be paid by me.
* I agree to pay the non-refundable $200 fee for the Learn to Row programme in full before 1 July 2019.

I accept the Terms & Conditions *
Required
Parent/Legal Guardian Name *
Your answer
Relationship to student *
Your answer
Contact Phone Number *
Your answer
Alternative Contact Name *
Your answer
Relationship of alternative contact to student *
Your answer
Contact Phone Number (for alternative contact) *
Your answer
A copy of your responses will be emailed to the address you provided.
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