Clwb Rhwyfo Porthmadog Rowing Club

Full Name:
DoB:
Address:

Post Code:
Tel:
Mb:
Email:

Next of Kin:
Tel:

Can you swim ? Yes/No
If no, you will need to wear a lifejacket.
As will all junior rowers up to the age of eighteen.

The questions below will indicate if you need to check with your Doctor before you start rowing. If you are over 50 years of age and not currently active, you should consult with your Doctor prior to commencing an exercise regime.

Please read the questions below and answer honestly (circle the most applicable answer):

? Has your Doctor ever said that you have a heart condition and you should only do physical activity recommended by a Doctor? Yes/No

? Do you have high blood pressure? Yes/No

? Do you have any pain in your chest when you do physical activity? Yes/No

? In the past have you ever had chest pain during physical activity? Yes/No

? Do you lose your balance because of dizziness or do you ever lose consciousness? Yes/No

? Do you have a bone or joint problem that could be made worse by a change in your physical activity? Yes/No

? Is your Doctor currently prescribing medication for you? Yes/No

? Do you know of any reason why you should not be undertaking physical activity? Yes/No

If you have answered any of the above questions with a yes you will need to consult with your GP before you start becoming more physically active. Your GP will advise whether rowing is a suitable activity for you.

DECLARATION: I have read, understood and completed the above questionnaire and acknowledge that there are risks and dangers inherent in rowing and physical exercise and duly undertake the activity at my own risk. Porthmadog Rowing Club and Madoc Yacht Club and their members shall not be held liable for any personal accident, accidental damage or loss of life while I am undertaking any rowing or rowing related activities.

Signed:

Date:

Parents Signature:
(If you are under 18)

Please return this form back to the Membership Secretary before your first row.

Membership Secretary

Tina Skinner
Madog Yacht Club
1 Corn Hill
Porthmadog

Tel: 01766 810273 / 07715 326664

Trackback URI | Comments RSS