Masters Weekly Membership

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Medical Information

List ALL medications taken *

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List all chronic illness or severe injuries *

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Waivers

Safe Sport Acknowledgement *

By clicking this box I acknowledge that I must also complete my Safe Sport Requirements.

Check here to sign HIPPA *

By checking this, in accordance with the Health Insurance Portability and Accountability Act of 1996 we are required to provide each rower or the rower’s parent or legally authorized representative with the Notice of Privacy Practices describing how we use and disclose patient health information.We will need the authorization signed in order for us to use or disclose athletic screening health information with the coaching staff. I authorize Sarasota Crew to release the results of the Pre-participation Physical Evaluation to the Coaching staff or personnel involved in the care of the athlete.I certify that this request has been made voluntarily. I understand that the information provided under this release may be subject to re-disclosure by the recipient under circumstances no longer protected by HIPPA Privacy Rules. I understand that I may revoke this release at any time, except to the extent that action has already been taken to comply with it. To revoke this authorization, I must provide written notice to the Administrative Director of Sarasota Crew.

Check here to sign the Release and Hold Harmless *

By checking this, I fully understand that playing or practicing to play interscholastic sports may be hazardous and poses a risk of injury to participants, others, and/or property damage, including but not limited to, sprains, strains, contusions, abrasions, broken bones and in extreme cases, paralysis or death. Due to the potential hazards associated with interscholastic sports, I recognize the importance of following the instructions of coaches and trainers regarding rowing techniques, training and other rules associated with this sport. I have comprehensive medical insurance that covers this rower for any expenses he/she may incur as the result of a sports related injury. In consideration of Sarasota Crew, Inc. permitting my child/ward to engage in interscholastic sports, specifically any rowing or rowing related activity which shall include scheduled,, supervised club activities (including, but not limited to practices, training, loading and unloading equipment, and intrasquad events) together with preparing for, transportation to and from, and participation in registered regattas (the “Activity” or “Activities”), I agree to release and hold harmless Sarasota Crew, Inc., Sarasota Bay Preserve, Historic Spanish Point and its employees, agents, officers, volunteers, sponsors, chaperones, etc. from and against all damages, claims, judgments, costs or any other expenses, including attorney fees, arising out of bodily injuries or property damage resulting from participation in interscholastic sports and/or the Activities. I acknowledge that I have read this agreement and that I will abide by all terms and rules associated with this sport and in this agreement. This agreement to participate in interscholastic sports and/or the Activities is entered into voluntarily and is made with the understanding that I have not violated any of the eligibility rules and regulations of Sarasota Crew, Inc. I acknowledge and agree that I am responsible to examine and inspect each interscholastic sport and/or Activity in which my child/ward may participate and that, if I observe any condition which I consider to be unacceptably hazardous or dangerous, I will notify the proper authority in charge of the interscholastic sport and/or Activity and will refuse to allow my child/ward to take part in the Activity, until the condition has been corrected to my satisfaction. I acknowledge that Sarasota Crew, Inc., has advised me that the Activities in which my child or ward may take part may involve coming into contact with water-borne microorganisms, bio-toxins, toxic contaminants and/or algae, including, but not limited to, those associated with “Red Tide”. I agree and warrant that if, I observe or deem any such condition 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. I hereby give my consent for my child/ward to engage in Sarasota Crew, Inc. approved interscholastic sport and/or Activities. I also give my consent for him/her to accompany the team as a member on out of town trips. From time to time various media and our own parents photograph, interview and video tape our rowers. I hereby give my consent for my child/ward to be interviewed, photographed or videotaped.

Check here to sign the Release and Hold Harmless for the Masters *

By checking this, I fully understand that playing or practicing to play sports may be hazardous and poses a risk of injury to participants, others, and/or property damage, including but not limited to, sprains, strains, contusions, abrasions, broken bones and in extreme cases, paralysis or death. Due to the potential hazards associated with sports, I recognize the importance of following the instructions of coaches and trainers regarding rowing techniques, training and other rules associated with this sport. I have comprehensive medical insurance that covers me for any expenses I may incur as the result of a sports related injury. In consideration of Sarasota Crew, Inc. I agree to release and hold harmless Sarasota Crew, Inc., Sarasota Bay Preserve, Historic Spanish Point and its employees, agents, officers, volunteers, sponsors, chaperones, etc. from and against all damages, claims, judgments, costs or any other expenses, including attorney fees, arising out of bodily injuries or property damage resulting from participation in sports and/or the Activities. I acknowledge that I have read this agreement and that I will abide by all terms and rules associated with this sport and in this agreement. This agreement to participate in sports and/or the Activities is entered into voluntarily and is made with the understanding that I have not violated any of the eligibility rules and regulations of Sarasota Crew, Inc. I acknowledge and agree that I am responsible to examine and inspect each c sport and/or Activity in which I may participate and that, if I observe any condition which I consider to be unacceptably hazardous or dangerous, I will notify the proper authority in charge of the sport and/or Activity and will refuse to take part in the Activity, until the condition has been corrected to my satisfaction. I acknowledge that Sarasota Crew, Inc., has advised me that the Activities in which I may take part may involve coming into contact with water-borne microorganisms, bio-toxins, toxic contaminants and/or algae, including, but not limited to, those associated with “Red Tide”. I agree and warrant that if, I observe or deem any such condition 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. I hereby give my consent for me engage in Sarasota Crew, Inc. approved sport and/or Activities. I also give my consent for him/her to accompany the team as a member on out of town trips. From time to time various media and our own staff photograph, interview and video tape our rowers. I hereby give my consent for me to be interviewed, photographed or videotaped.

Signature for Consent to Treat , HIPPA, and Hold Harmless for Masters *

Date for Signature of the Consent to Treat, HIPPA, and Hold Harmless *

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