2012 US Rowing Development Camp for Persons with Intellectual Disability
Athlete Information Form
Name:_____________________________________________ Today’s date:___________________
Phone #:___________________________ E-Mail:___________________________________Birthdate:________________
Parent/Coach/ Name_________________________ Phone_________________________ Email:_____________________
In case of emergency, whom should we contact:___________________________________ Cell #____________________
Section I: General Questions
Describe your swimming ability:
Describe your rowing experience (please be specific):
Section 2: Medical Information and History
Have you ever had any of the following? (please chech the yes or no column)
Are you greatly affected by heat?
High Blood Pressure
Are you taking medication?
Do you get cold easily?
If yes, are there any side effects of the medication such as sun sensitivity, increased thirst, or fatigue?
Are you allergic to insect bites or bee stings
If yes, do you carry medication?
If yes what triggers them?
If yes, what is the date of you last seizure?
***If you answered YES to any of the medical questions, please explain:
*So that we can better understand your needs, please list any medical, physical, psychological, or emotional issues not mentioned above: Please note type of learner – visual/ auditory, etc
What interests you about attending the Development Rowing Camp?
What do you hope to get out of Camp participation? (Your Goals):
Please attach with this form, your payment & the following documentation:
Evidence of fitness (submit current training + any competition results showing times and distances raced—any sport.
Evidence of being able to tread water for 5 minutes
Meet intellectual disability criteria (www.athleteswithoutlimits.org) Please state IQ/ Diagnoses an Adaptive Score if available and age of onset
***Please return this Form; Documentation and Camp Fee: $200 to:
Please make checks payable to Texas Rowing For All & send to:
Diane Mc Diarmid
Texas Rowing For All
US Paralympic Sport Club
5715 Bexley Ct.
Austin, Texas 78739