WCR-B Medical Consent Form

WCR-B MEDICAL CONSENT FORM (Printer-Friendly)

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MEDICAL CONSENT FORM

Rowing is a strenuous physical sport. All participants must be screened by a physician prior to beginning the WeCanRow program. Please print the form, fill Part One out completely, have your physician complete Part Two and sign where indicated, and return it to WeCanRow-Boston by May 1. (If you return a scanned copy by email, please either mail the original to the address below or bring it to your Learn To Row session.) This information will be used only for the purposes of the WeCanRow-Boston program.

PART ONEto be completed by participant

Name of Participant: _____________________________________________________

Date of Birth: ___________________________________________________________

Medications: ____________________________________________________________

Allergies: ______________________________________________________________

Please list any physical disorders or health restrictions that may adversely affect your ability to row safely and any information you would like the rowing coaches to know.

______________________________________________________________________

 

Signature: ____________________________               Date: _____________________

PART TWOto be completed by physician

___________________________ is my patient, is in good health and free of physical limitations other than as listed above, and is able to participate in the WeCanRow-Boston rowing program.

Signature: _______________________________            Date: ____________________

                        (no stamped signatures)

Print Name: _______________________________________

Address: _________________________________________

Phone Number: ___________________________________

WeCanRow-Boston
P.O.Box 750036                                                                     http://wecanrowboston.org/
Arlington, MA. 02475                                                          wecanrowboston@yahoo.com