Broad Run Crew Learn to Row 2019
Sign up to participate in Learn to Row at Algonkian Park June 10-14 5:30 - 7:30 p..m. by completing the form below.

In addition to filling out this form, please use the following link to download the Broad Run Crew Liability Waiver.  Please complete, sign, and return the waiver with your $175 check made payable to BROAD RUN CREW to:

Broad Run Athletic Dept.
Attn: Crew
21670 Ashburn Rd.
Ashburn, VA  20147

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Rower's First Name *
Rower's Last Name *
Rower's Email Address *
Rower's Gender *
 Rower's Address *
Grade for 2019-2020 School Year *
School Attended *
Date of Birth
MM
/
DD
/
YYYY
T-Shirt Size (Adult Sizes) *
Parent's Name(s) *
Parent's Email Address *
Parent's Phone Number *
Emergency Contact *
Emergency Contact Phone Number *
In the event of an emergency requiring medical attention, I grant permission to a physician or other hospital personnel designated by the Broad Run Crew Coaching Staff to attend my child. *
In order to participate in Broad Run Crew learn to row you must have proper and adequate medical insurance.  Please indicate that your child has medical insurance. *
Health Insurance Subscriber *
Health Insurance Company *
Does your child wear contact lenses or glasses? *
Has your child ever had any of the following? *
Yes
No
Asthma
Diabetes
Kidney Injury
Heart Condition
Allergies
Epi Pen needed
Please list allergies:
Please note any other conditions that should be brought to the coaches' or a physician's attention.
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