WCR-B MEDICAL CONSENT FORM (Printer-Friendly)
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 ONE – to be completed by participant
Name of Participant: _____________________________________________________
Date of Birth: ___________________________________________________________
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 TWO – to 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: _______________________________________
Phone Number: ___________________________________
P.O.Box 750036 http://wecanrowboston.org/
Arlington, MA. 02475 firstname.lastname@example.org