Head of the Charles Row Over Waiver

Community Rowing, Inc., Signup Information and Waiver

Date: ________________________________________________

Rowing Activity/Event: ___________________________________________________________________

Rower Name: ______________________________ Date of Birth: ______________ Gender: M / F (circle)

Rower Address: _________________________________________________________________________

Rower E-Mail: ______________________________ Rower Phone Number: _________________________

Affiliation (leave blank if unaffiliated): _______________________________________________________

Health Information:

Do you have any physical disorder or health condition (such as asthma, diabetes, heart problem, seizures, back, joint or muscle problems) or any condition that may affect your ability to row safely, or other conditions that your coach should know about? YES / NO

If YES, please explain: ____________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

I understand that my participation involves rowing in an open craft in a physically demanding activity where there may be unusual risks to my health and safety. In addition, I understand that certain on-shore activities, such as carrying boats, may pose unusual risks 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 and that I will notify my coach if I have or if I develop any physical problem or health condition that may affect my ability to participate in these activities without posing a danger to my health or safety, or the health or safety of others. In consideration of your acceptance of this application, I hereby agree for myself, me executors, administrators and assigns to hold harmless Community Rowing, Inc., and its directors, officers, employees, representatives, successors, agents and assigns from all liability on account of injury, 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.

Rower Signature: ________________________________________ Date: __________________________

If Under 18:

Parent/Guardian: _________________________ Address: ______________________________________

Parent/Guardian Phone: ____________________ E-mail: ________________________________________

Parent/Guardian Signature: ________________________________ Date: __________________________