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APPLICATION for ROWING MEMBESHIP 2015
QUINTE ROWING CLUB INC.
ADULT ⃝
STUDENT ⃝
RCA # ___________________
PARTICIPANT INFORMATION
DD/ MM/ YY
Name: ______________________________________________________
Date of Birth
___/____/____
Street ______________________________________________________
R.R.# ____
City ________________________________________________________
Postal Code __________________
Phone (H) _______________________ (C) _______________________
E-mail _______________________________________
Do you wish to receive information via e-mail? Y / N
Would you like to have your name visible on the e-mail to all recipients? Y / N
EMERGENCY CONTACTS
Name:
1.
2.
Relation
_______________________________________
_______________________________________
ROWING EXPERIENCE? Y /N Level _________
Health Card # - (optional) ____________________________
______________________
______________________
Phone #
___________________
___________________
Swimming Experience Y /N
PCO Card Y/ N
RELEVANT MEDICAL INFORMATION (Briefly state any allergies, injuries, medications, physical limitations or
personal conditions which may influence your ability to perform in some of the rowing activities)
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
RELEASE, WAIVER AND ASSUMPTION OF RISK
I, _____________________ acknowledge and agree that in consideration of being permitted to participate in the activities
of the Quinte Rowing Club Inc., to release the Quinte Rowing Club Inc., the City of Belleville, the agents, servants and
employees from any claims of any kind, and represent that:
1.
2.
3.
I have the ability to swim;
I agree to comply with the rules, regulations, instructions and safety regulations concerning the Quinte Rowing
Club Inc.;
I am aware that certain risks exist in the performance, activities and programs of the Quinte Rowing Club Inc.
Among other things, these risks include adverse weather, exposure to the elements, capsizing, collision with
other vessels and drowning. Such risks as well as unexpected and unforeseen events or conditions could lead to
physical injury or death. I voluntarily participate in these programs and utilize various Quinte Rowing Club
Inc. facilities and equipment and recognize that risks also exist associated with travel, competitions such as
rowing and ergometer regattas, and with knowledge of the dangers and responsibilities involved, do accept any
and all risk of injury or death.
DD / MM / YY
Signature of Rower: _________________________________________________________ Date: ___ /___ /____
Signature of Parent or Guardian: _____________________________________________ Date: ___ / ___ /____
(over)
INFORMATION DISCLOSURE STATEMENTS
I grant the Club permission to disclose my personal information to ROWING CANADA AVIRON (RCA) and
ROWONTARIO (ORA) for the reasons listed below. Circle Yes or No.
YES / NO
Receiving solicitation from RCA’s sponsors such as MBNA
YES / NO
Receiving advertisements from RCA’s sponsors about their products or services through
mailings done within RCA
YES /NO
Receiving solicitation from within RCA for fundraising or other commercial activities
Signature of Member/Parent or Guardian : ______________________________________ Date: ______________________
I grant the Club permission to use my picture for postings on
YES/ N0
Quinte Rowing Club Website
YES/ NO
Quinte Rowing Club Facebook Page
YES NO
Events or promotions in local newspapers or other printed matter
Signature of Member/Parent or Guardian: _____________________________________
Date: _______________________
OFFICE USE ONLY___________________________________________________________________________________________
MEMBERSHIP COST (April 1 – October 31) $350 plus 20 volunteer hours
Payment Options: A: $350 payment
B: $200 payment
- cheque # _________ or cash _______
-cheque # _________ or cash ______
plus $150 post-dated cheque for July 1
-cheque # _________
Registration as Competitive Member -an additional $75 _________
Gym Use Extension of Membership (November 1 – March 31) $150 plus additional 10 hours
Payable Prior to October 31st
- cheque # _______ or cash _______
Payment received by _________________________________
Volunteer hours Completed _____
Date: ___________________
Amount Owing for hours not worked ____hr. X $10 == $_________
KEY CARD: $20 Deposit on file for Card # ________________
$20 Deposit made for Card # ________________
BOAT STORAGE FEES – Single $100 ______
Received by: ______________ (Initial & Date)
Double $125 _______
Payment Received: $___________
Initial & Date: _________________