Saturday, August 2, 2014 Captain s Cove Seaport, Bridgeport, CT. Two-Person Relay Application. Sponsored by:

Transcription

1 The St. Vincent s SWIM Acrss the Sund Marathn Saturday, August 2, 2014 Captain s Cve Seaprt, Bridgeprt, CT Tw-Persn Relay Applicatin Spnsred by:

2 SWIM MARATHON RULES & GUIDELINES TWO-PERSON RELAY SWIMMERS 1. CLOTHING: One suit, swim cap, gggles, earplugs and grease will be allwed. Fr wmen, suits that cver up t their neck and dwn t their knees are acceptable. Fr men, suits may nt cver their trs, nr g belw their knees. Neither men nr wmen may wear suits that cver their shulders in any way. All suits must be f the traditinal swimming style lycra type suits. Swimmers must wear the prvided swim cap. 2. ASSISTANCE: Tw-persn relay swimmers may nt use fltatin aids, prpulsin devices, r any ther devices t maintain bdy heat. Wetsuits, fins, hand paddles, pull buys r bards are strictly prhibited. Pacing, drafting and twing are nt allwed. Swimmers may nt tuch the escrt bat r any ther bat during the SWIM. A vilatin f this rule shall result in disqualificatin. All tw-persn relay swimmers shuld bring ne crew member t prvide feeding assistance. If a swimmer is unable t bring their wn crew, please ntify the race cmmittee and we will use ur best effrts t prvide yu a crew member. Swimmers are required t bring their wn fd fr the swim. The use f alchl r drugs is strictly frbidden. 3. QUALIFYING SWIM: All tw-persn relay applicants must submit prf f a fur-hur r lnger qualifying swim in pen water cmpleted within the past 18 mnths in rder t be eligible t participate in the event. Swimmers wh have successfully cmpleted any f the fllwing swims within the past 18 mnths are exempt frm the fur-hur qualifier swim: Catalina Island Channel SWIM Acrss the Sund English Channel Tampa Bay 24 mile Marathn Swim Lake Memphremagg Fur-Hur Qualifying Swim* Manhattan Island Marathn Swim Other USA/USMS distance swim > 10 miles Rund Jersey Swim (Channel Islands) * Please cmplete and submit the Qualifying Swim-Observer Reprrt and Qualifying Lg. Applicants must submit this requirement by the dcumentatin deadline. 4. AGE MINIMUM: Tw-persn relay swimmers must be 19 years ld n r befre December 31 f the year f the event, in accrdance with FINA Age Rules. Exceptins may be cnsidered under the discretin f the SWIM Cmmittee. 5. TWO-PERSON RELAY INSTRUCTIONS: Swimmers must alternate every 30 minutes (n exceptins). The rder f the swimmers must be maintained thrughut the swim. The transitin frm ne swimmer t the next must be executed by appraching the swimmer in the water frm behind, and the transitin is cnsidered cmplete when the entering swimmer fully passes the departing swimmer. Relay team members must enter the water feet first. Failure t fllw these rules will result in disqualificatin. 6. MEDICAL EXAMINATION: Bth swimmers must have their primary physician fully cmplete the required medical frm. Tw-Persn Relay Applicatin - Rules & Guidelines Page 1 f 1

3 INSTRUCTIONS FOR RELAY TEAM CAPTAINS BEFORE YOU START If yu have previusly participated in the SWIM Marathn (r since 2007), please use yur existing User ID and passwrd If yu have nt previusly participated in the SWIM Marathn, please cntinue with the nline registratin prcess. It will allw yu t create a new user ID and passwrd Make sure yu have the full legal name (NO nicknames) and addresses f yur team members REGISTRATION IS A THREE STEP PROCESS 1. Cmplete the nline Registratin Frm 2. Print, cmplete and sign the Applicatin Frm 3. After the Team Captain has cmpleted the nline Applicatin Prcess, a cmputer generated will be sent t the team members with a link t prmpt them t register. In additin t registering nline, team members must als print, cmplete and sign the team member prtin f the written applicatin HOW TO COMPLETE THE ONLINE REGISTRATION FORM Register by inputting the fllwing: Cntact infrmatin Accunt Infrmatin Accident and Release f Liability Waiver Accept Waiver bx must be checked Jin Optins Click n Create a New Team Set Team Gal Enter dllar amunt in bx (Relay team gal is $7,500) Create the Team Type click n Relay Team frm the pull dwn Input New Team Name Event Optins There can nly be ne Team Captain whether they are swimming r nn-swimming Team Captain (Relays) bx input 1 frm the pull dwn If yu re a Team Captain wh is swimming 5 team members can be input If yu re a Team Captain wh is nt swimming 6 team members can be input Tw-Persn Relay Applicatin - Team Captain Page 1 f 4

4 INSTRUCTIONS FOR RELAY TEAM CAPTAINS Payment Verify billing infrmatin Enter payment infrmatin A nn-refundable entry fee payment f $200 is due with the applicatin submitted by a sl swimmer r team captain. This amunt will be included in yur fundraising gal Click Register Cnfirmatin Team Captain will receive cnfirmatin f a successful registratin An message will be sent t each team member with a website link t take them t relay team member registratin. Each team member shuld cmplete the nline registratin. Team Captains must then dwnlad, print, cmplete and sign the Applicatin Frm (Offline Frm) My Dashbard Click n My Team Click n Add New Team Member Input the full legal names (NO nicknames) and addresses f the team members - One additinal team member may be added t teams with nn-swimming team captains. Set up a team page with infrmatin and pictures HOW TO COMPLETE THE PAPER APPLICATION FORM Click n this link: Click n Team Relay Swimmer Applicatin Print, cmplete and sign applicatin (this is an ffline, paper applicatin) , fax r mail the cmpleted frm t: PFignar@stvincents.rg AND SwimAcrssTheSund.Sharn@gmail.rg Fax (203) Mail t: St. Vincent s Medical Center Fundatin Attn: Patti Fignar 2800 Main Street Bridgeprt, CT a high-reslutin (300 dpi) digital pht t: Debrah.Cx@stvincents.rg Please ensure that the security settings n yur prgram allw incming mail frm senders at LizFry.MarathnDirectr@SwimAcrssTheSund.rg, dcards@stvincents.rg, debrah.cx@stvincents.rg, pfignar@stvincents.rg, eafry@al.cm, SwimAcrssTheSund.Sharn@gmail.rg. Tw-Persn Relay Applicatin - Team Captain Page 2 f 4

5 TEAM CAPTAIN TWO-PERSON RELAY APPLICATION TEAM INFORMATION (T be cmpleted by Team Captain.) Please nte: Use full legal name (n nicknames r abbreviatins). Team Name: Team Captain r Cach Name: Captain/Cach Phne: Captain/Cach Swimmer #1 Age*: Swimmer #2 Age*: In rder t keep the flw f infrmatin cnsistent and accurate, any questins r infrmatin needs by team members shuld be cmmunicated by the Captain r Cach t the SWIM Cmmittee. Are yu representing a club, rganizatin r crpratin? If yes, please explain! Acknwledgement f Cmmitment I acknwledge and understand that cmpeting in such an event is an extreme test f each team member s swimming ability, mental tughness and physical cnditining. I have selected the team members with these cnditins in mind and believe that each team member is physically fit and capable f swimming in this event. I als acknwledge that the fundraising cmmitment fr the team is $3,500 and that the team is cmmitted t reaching and hpefully exceeding this gal. Team Captain Date *Day f SWIM Tw-Persn Relay Applicatin - Team Captain Page 3 f 4

6 TEAM CAPTAIN TWO-PERSON RELAY APPLICATION - CREW INFORMATION TO BE COMPLETED BY TEAM CAPTAIN Use full legal name (n nicknames r abbreviatins). Team Name: CREW #1 Name: Address: City, State, Zip Phne: Wrk Phne: Cell Phne: Is Cell available n race day? Relatinship/Age: T-shirt Size: Is crew member a certified lifeguard? Yes N Is crew member a certified EMT? Yes N CREW #2 (ALTERNATE) Name: Address: City, State, Zip Phne: Wrk Phne: Cell Phne: Is Cell available n race day? Relatinship/Age: T-shirt Size: Is crew member a certified lifeguard? Yes N Is crew member a certified EMT? Yes N Crew members and alternates will receive an with instructins n crew enrllment nce the sl swimmers r team has been accepted fr the SWIM. Crew members and alternates must cnfirm participatin by cmpleting the crew member s enrllment and waiver. Tw-Persn Relay Applicatin - Team Captain Page 4 f 4

7 SWIMMER #1 TWO-PERSON RELAY APPLICATION PERSONAL INFORMATION Use full legal name (n nicknames r abbreviatins). Team Name: Team Captain: Swimmer #1 Full Legal Name: Address: City, State, Zip, Cuntry Hme Phne: Cell Phne: Cntact Gender: DOB: (mm/dd/yy) Age: T-shirt size: Height: Weight: Please nte: yur name, age, hmetwn and backgrund infrmatin may be used fr media relatins and prmtinal purpses. Yur cntact infrmatin may be used t reach yu fr media inquiries, but will never be published withut yur granted cnsent. WORK INFORMATION Occupatin & Title: Emplyer: Emplyer Address: City, State, Zip Cuntry Phne: Fax: Des Yur Emplyer Match Charitable Dnatins? Yes N EMERGENCY CONTACT INFORMATION Name: Hme Phne: Relatinship: Cell Phne: Tw-Persn Relay Applicatin - Swimmer #1 Page 1 f 8

8 SWIMMER #1 TWO-PERSON RELAY APPLICATION ACCIDENT AND RELEASE OF LIABILITY WAIVER I acknwledge that this 25km athletic event is an extreme test f a persn s physical and mental limits and hereby certify that I am physically fit and have nt been therwise infrmed by a physician. I acknwledge that I am aware f all f the risks inherent in Open Water Swimming (training and cmpetitin), including pssible permanent disability r death, and agree t assume all thse risks. I acknwledge that this Accident and Release f Liability Waiver will be used by the event hlders, spnsrs and rganizers f the event f the SWIM Acrss the Sund, and that it will gvern my actins and respnsibilities at such event. AS A CONDITION OF MY PARTICIPATION IN THE SWIM ACROSS THE SOUND OR ANY ACTIVITIES INCIDENT THERETO, I HEREBY WAIVE ANY AND ALL RIGHTS TO CLAIMS FOR LOSS OR DAMAGES, INCLUDING ALL CLAIMS FOR LOSS OR DAMAGES CAUSED BY THE NEGLIGENCE, ACTIVE OR PASSIVE, OF THE FOLLOWING: ST. VINCENT S HEALTH SERVICES, ST. VINCENT S MEDICAL CENTER, ST. VINCENT S MEDICAL CENTER FOUNDATION, SWIM ACROSS THE SOUND, CITY OF BRIDGEPORT, CAPTAINS COVE MARINA, DANFORDS MARINA, ALL PARTICIPATING POLICE AND FIRE DEPTS FROM VARIOUS TOWNS, STATES OF CT AND NY, HOST FACILITIES, EVENT SPONSORS, VOLUNTEERS, BOAT CAPTAINS, EVENT COMMITTEES, OR ANY INDIVIDUALS OFFICIATING AT THE EVENTS OR SUPERVISING SUCH ACTIVITIES. In additin, I als agree t abide by and be gverned by the rules established by the SWIM Cmmittee. Finally, I specifically acknwledge that I am aware f all the risks inherent in pen water swimming and agree t assume thse risks. Print Swimmer s Full Legal Name Age Signature Date If Swimmer is under the Age f 19, signature f parent r guardian is als required. Print Parent/Guardian Name Age Signature f Parent r Guardian Date Tw-Persn Relay Applicatin - Swimmer #1 Page 2 f 8

9 SWIMMER #1 TWO-PERSON RELAY APPLICANT - QUALIFYING SWIM Swimmer #1 Full Legal Name: Each Tw-Persn Relay applicant must submit prf f a fur-hur r lnger qualifying swim in pen water cmpleted within 18 mnths f the event t be eligible t participate. Number f marathn swims Qualifying Swim Catalina Island Channel English Channel Lake Memphremagg Manhattan Island Marathn Swim Rund Jersey Swim SWIM Acrss the Sund (sl) Tampa Bay 24 mile Marathn Swim Fur-hur Qualifying Swim* Other USA/USMS distance swim (>10 miles) Time - Date (please enter Pending if nt cmpleted at time f applicatin) * Please cmplete and submit the Qualifying Swim Observer Reprt and Qualifying Swim Lg. Applicants must submit this requirement by the dcumentatin deadline. Fur-hur Qualifying Swim shuld be fur hurs f cntinuus swimming, with in-water feedings (if at all pssible) t try t duplicate the rutine yu will encunter in SAS. Yu shuld try t have a few peple with yu in rder t assist in this qualifying swim s they can keep yur lg and help yu with the feedings. Yu may als have ther swimmers accmpany yu n this swim and can g as fast r slw as yu desire. An example f a qualifying swim lg is enclsed in this packet. After cmpletin f yur qualifying swim, yur bserver shuld submit the frm belw n yur behalf. If yu are exempt frm a Fur-hur Qualifying Swim, please submit cpies f fficial race results r ther dcumentatin frm ne f the ther events abve. OBSERVER NAME: ADDRESS: PHONE / QUALIFYING SWIM - OBSERVER REPORT I, attest that swam cntinuusly fr fur hurs n, at beach lcated in the city f in the state f. Based upn this swim, I believe he/she is qualified t cmpete in the SWIM Acrss the Sund. I have attached a lg frm his qualifying swim. Signed Signature Tw-Persn Relay Applicatin - Swimmer #1 Page 3 f 8

10 SWIMMER #1 TWO-PERSON RELAY APPLICATION - MEDICAL FORM Swimmer #1 Full Legal Name: DOB: Parts 1 & 2 must be cmpleted and enclsed with yur applicatin. INCOMPLETE MEDICAL FORMS WILL CAUSE YOUR APPLICATION TO BE DELAYED OR REJECTED. If yu answer yes t any questins, yu must prvide an explanatin n the back f this frm. PART I: MEDICAL HISTORY (t be cmpleted by Swimmer) 1. Have yu ever suffered at any time frm the fllwing: a. Ear truble, earache r deafness? YES NO b. Sinus truble? YES NO c. Chest disease, including asthma, brnchitis, TB, cllapse lung? YES NO d. Blackuts r fainting? YES NO e. Nervus disrders, cncussins? YES NO f. Anxiety, nerves r nervus breakdwns? YES NO g. Heart Disease? YES NO h. High Bld Pressure? YES NO i. Diabetes? YES NO 2. D yu regularly r frequently take medicatins with r withut prescriptin? YES NO 3. Are yu currently receiving medical care r cnsulted a dctr in the last year? YES NO 4. Have yu ever failed a medical exam r been refused life insurance? YES NO 5. Have yu been t the hspital in the last year? YES NO 6. D yu smke r use illegal drugs? YES NO 7. D yu have any allergies t medicatin? YES NO 8. D yu have any rthpedic prblems? YES NO 9. D yu wear any prstheses? YES NO I certify that t the best f my knwledge, I am in gd health and that I have nt mitted any infrmatin which may be relevant t my fitness t swim. I authrize my medical dctr t disclse any detail f my past r present medical histry if requested t d s by the SWIM cmmittee r applicatin review panel. Signed: Date: PART II: DOCTOR S EXAMINATION The abve named swimmer wishes t be examined t determine his/her physical fitness t participate in a 25km SWIM Acrss Lng Island Sund. Please nte that this is an extreme test f physical and mental endurance. Height: Weight: Bld Pressure: Pulse: Ears: R. Drum: R. Canal: L. Drum: L. Canal: Sinuses: Nse: Thrat: Chest: Cardi Sys: Nervus Sys: Jints: Limbs: ECG: Urine-Albumin Urine-Glucse: NOTE: The Swim encurages and welcmes swimmers with disabilities. REMARKS: Any remarks abut the swimmers physical cnditin shuld be written n the back f this frm. AFTER EXAMINATION, I CONSIDER (print swimmer name) TO BE FIT r UNFIT t participate in this SWIM. Examining Dctr Print Name SIGN DATE Tw-Persn Relay Applicatin - Swimmer #1 Page 4 f 8

11 SWIMMER #1 TWO-PERSON RELAY APPLICATION - PERSONAL STORY Swimmer #1 Full Legal Name: Have yu ever participated in the SWIM Acrss the Sund? Yes N If yes, when? What is yur persnal fundraising gal? (The minimum fundraising cmmitment is $3,500) $ What made yu interested t participate in the SWIM? Are yu swimming in hnr f smene? Any ther infrmatin yu wuld like t share? Tw-Persn Relay Applicatin - Swimmer #1 Page 5 f 8

12 SWIMMER #1 TWO-PERSON RELAY APPLICATION - SWIMMING BACKGROUND Swimmer #1 Full Legal Name: Each Tw-Persn Relay applicant must have cmpleted a fur-hur r lnger qualifying swim. Prf must be submitted by the dcumentatin deadline. PLEASE LIST SOME OF YOUR MOST RECENT OPEN WATER EVENTS: (attach dcumentatin) Event Name: Lcatin/Distance: Date: Finishing Time: Water Temp: Winner Finish Time: What was yur place? Event Name: Lcatin/Distance: Date: Finishing Time: Water Temp: Winner Finish Time: What was yur place? Event Name: Lcatin/Distance: Date: Finishing Time: Water Temp: Winner Finish Time: What was yur place? Event Name: Lcatin/Distance: Date: Finishing Time: Water Temp: Winner Finish Time: What was yur place? OPEN WATER SWIMS PLANNED FOR CURRENT YEAR: Swim #1 Lcatin: Distance: Swim #2 Lcatin: Distance: Swim #3 Lcatin: Distance: OTHER ATHLETIC ACHIEVEMENTS: PHOTO: Please a high-reslutin (300 dpi) pht f yurself t Debrah.Cx@stvincents.rg alng with yur first and last name. We may use this fr the lcal media and prmtinal materials. Tw-Persn Relay Applicatin - Swimmer #1 Page 6 f 8

13 SWIMMER #1 QUALIFYING SWIM LOG - PAGE 1 USE FULL LEGAL NAMES (NO NICKNAMES OR ABBREVIATIONS). Swimmer #1 Name: Date: Start Time: START: Air Temp and Cnditins: Water Temp and Cnditins: Swimmer s Mental and Physical Cnditins: Feeding Schedule (Interval/Liquid Type/Gel): Lcatin f Swim: Observer: Finish Time: ACTUAL TIME: HOUR 1: Air Temp and Cnditins: Water Temp and Cnditins: Swimmer s Mental and Physical Cnditins: Feeding: Strke rate per minute: ACTUAL TIME: HOUR 2: Air Temp and Cnditins: Water Temp and Cnditins: Swimmer s Mental and Physical Cnditins: Feeding: Strke rate per minute: ACTUAL TIME: HOUR 3: Air Temp and Cnditins: Water Temp and Cnditins: Swimmer s Mental and Physical Cnditins: Feeding: Strke rate per minute: ACTUAL TIME: Tw-Persn Relay Applicatin - Swimmer #1 Page 7 f 8

14 SWIMMER #1 QUALIFYING SWIM LOG - PAGE 2 Swimmer #1 Full Legal Name: HOUR 4: Air Temp and Cnditins: Water Temp and Cnditins: Swimmer s Mental and Physical Cnditins: Feeding: Strke rate per minute: ACTUAL TIME: Ttal time f the Swim COMMENTS: Tw-Persn Relay Applicatin - Swimmer #1 Page 8 f 8

15 SWIMMER #2 TWO-PERSON RELAY APPLICATION PERSONAL INFORMATION Use full legal name (n nicknames r abbreviatins). Team Name: Team Captain: Swimmer #2 Full Legal Name: Address: City, State, Zip, Cuntry Hme Phne: Cell Phne: Cntact Gender: DOB: (mm/dd/yy) Age: T-shirt size: Height: Weight: Please nte: yur name, age, hmetwn and backgrund infrmatin may be used fr media relatins and prmtinal purpses. Yur cntact infrmatin may be used t reach yu fr media inquiries, but will never be published withut yur granted cnsent. WORK INFORMATION Occupatin & Title: Emplyer: Emplyer Address: City, State, Zip Cuntry Phne: Fax: Des Yur Emplyer Match Charitable Dnatins? Yes N EMERGENCY CONTACT INFORMATION Name: Hme Phne: Relatinship: Cell Phne: Tw-Persn Relay Applicatin - Swimmer #2 Page 1 f 8

16 SWIMMER #2 TWO-PERSON RELAY APPLICATION ACCIDENT AND RELEASE OF LIABILITY WAIVER I acknwledge that this 25km athletic event is an extreme test f a persn s physical and mental limits and hereby certify that I am physically fit and have nt been therwise infrmed by a physician. I acknwledge that I am aware f all f the risks inherent in Open Water Swimming (training and cmpetitin), including pssible permanent disability r death, and agree t assume all thse risks. I acknwledge that this Accident and Release f Liability Waiver will be used by the event hlders, spnsrs and rganizers f the event f the SWIM Acrss the Sund, and that it will gvern my actins and respnsibilities at such event. AS A CONDITION OF MY PARTICIPATION IN THE SWIM ACROSS THE SOUND OR ANY ACTIVITIES INCIDENT THERETO, I HEREBY WAIVE ANY AND ALL RIGHTS TO CLAIMS FOR LOSS OR DAMAGES, INCLUDING ALL CLAIMS FOR LOSS OR DAMAGES CAUSED BY THE NEGLIGENCE, ACTIVE OR PASSIVE, OF THE FOLLOWING: ST. VINCENT S HEALTH SERVICES, ST. VINCENT S MEDICAL CENTER, ST. VINCENT S MEDICAL CENTER FOUNDATION, SWIM ACROSS THE SOUND, CITY OF BRIDGEPORT, CAPTAINS COVE MARINA, DANFORDS MARINA, ALL PARTICIPATING POLICE AND FIRE DEPTS FROM VARIOUS TOWNS, STATES OF CT AND NY, HOST FACILITIES, EVENT SPONSORS, VOLUNTEERS, BOAT CAPTAINS, EVENT COMMITTEES, OR ANY INDIVIDUALS OFFICIATING AT THE EVENTS OR SUPERVISING SUCH ACTIVITIES. In additin, I als agree t abide by and be gverned by the rules established by the SWIM Cmmittee. Finally, I specifically acknwledge that I am aware f all the risks inherent in pen water swimming and agree t assume thse risks. Print Swimmer s Full Legal Name Age Signature Date If Swimmer is under the Age f 19, signature f parent r guardian is als required. Print Parent/Guardian Name Age Signature f Parent r Guardian Date Tw-Persn Relay Applicatin - Swimmer #2 Page 2 f 8

17 SWIMMER #2 Swimmer #2 Full Legal Name: TWO-PERSON RELAY APPLICANT - QUALIFYING SWIM Each Tw-Persn Relay applicant must submit prf f a fur-hur r lnger qualifying swim in pen water cmpleted within 18 mnths f the event t be eligible t participate. Number f marathn swims Qualifying Swim Catalina Island Channel English Channel Lake Memphremagg Manhattan Island Marathn Swim Rund Jersey Swim SWIM Acrss the Sund (sl) Tampa Bay 24 mile Marathn Swim Fur-hur Qualifying Swim* Other USA/USMS distance swim (>10 miles) Time - Date (please enter Pending if nt cmpleted at time f applicatin) * Please cmplete and submit the Qualifying Swim Observer Reprt and Qualifying Swim Lg. Applicants must submit this requirement by the dcumentatin deadline. Fur-hur Qualifying Swim shuld be fur hurs f cntinuus swimming, with in-water feedings (if at all pssible) t try t duplicate the rutine yu will encunter in SAS. Yu shuld try t have a few peple with yu in rder t assist in this qualifying swim s they can keep yur lg and help yu with the feedings. Yu may als have ther swimmers accmpany yu n this swim and can g as fast r slw as yu desire. An example f a qualifying swim lg is enclsed in this packet. After cmpletin f yur qualifying swim, yur bserver shuld submit the frm belw n yur behalf. If yu are exempt frm a Fur-hur Qualifying Swim, please submit cpies f fficial race results r ther dcumentatin frm ne f the ther events abve. OBSERVER NAME: ADDRESS: PHONE / QUALIFYING SWIM - OBSERVER REPORT I, attest that swam cntinuusly fr fur hurs n, at beach lcated in the city f in the state f. Based upn this swim, I believe he/she is qualified t cmpete in the SWIM Acrss the Sund. I have attached a lg frm his qualifying swim. Signed Signature Tw-Persn Relay Applicatin - Swimmer #2 Page 3 f 8

18 SWIMMER #2 TWO-PERSON RELAY APPLICATION - MEDICAL FORM Swimmer #2 Full Legal Name: DOB: Parts 1 & 2 must be cmpleted and enclsed with yur applicatin. INCOMPLETE MEDICAL FORMS WILL CAUSE YOUR APPLICATION TO BE DELAYED OR REJECTED. If yu answer yes t any questins, yu must prvide an explanatin n the back f this frm. PART I: MEDICAL HISTORY (t be cmpleted by Swimmer) 1. Have yu ever suffered at any time frm the fllwing: a. Ear truble, earache r deafness? YES NO b. Sinus truble? YES NO c. Chest disease, including asthma, brnchitis, TB, cllapse lung? YES NO d. Blackuts r fainting? YES NO e. Nervus disrders, cncussins? YES NO f. Anxiety, nerves r nervus breakdwns? YES NO g. Heart Disease? YES NO h. High Bld Pressure? YES NO i. Diabetes? YES NO 2. D yu regularly r frequently take medicatins with r withut prescriptin? YES NO 3. Are yu currently receiving medical care r cnsulted a dctr in the last year? YES NO 4. Have yu ever failed a medical exam r been refused life insurance? YES NO 5. Have yu been t the hspital in the last year? YES NO 6. D yu smke r use illegal drugs? YES NO 7. D yu have any allergies t medicatin? YES NO 8. D yu have any rthpedic prblems? YES NO 9. D yu wear any prstheses? YES NO I certify that t the best f my knwledge, I am in gd health and that I have nt mitted any infrmatin which may be relevant t my fitness t swim. I authrize my medical dctr t disclse any detail f my past r present medical histry if requested t d s by the SWIM cmmittee r applicatin review panel. Signed: Date: PART II: DOCTOR S EXAMINATION The abve named swimmer wishes t be examined t determine his/her physical fitness t participate in a 25km SWIM Acrss Lng Island Sund. Please nte that this is an extreme test f physical and mental endurance. Height: Weight: Bld Pressure: Pulse: Ears: R. Drum: R. Canal: L. Drum: L. Canal: Sinuses: Nse: Thrat: Chest: Cardi Sys: Nervus Sys: Jints: Limbs: ECG: Urine-Albumin Urine-Glucse: NOTE: The Swim encurages and welcmes swimmers with disabilities. REMARKS: Any remarks abut the swimmers physical cnditin shuld be written n the back f this frm. AFTER EXAMINATION, I CONSIDER (print swimmer name) TO BE FIT r UNFIT t participate in this SWIM. Examining Dctr Print Name SIGN DATE Tw-Persn Relay Applicatin - Swimmer #2 Page 4 f 8

19 SWIMMER #2 TWO-PERSON RELAY APPLICATION - PERSONAL STORY Swimmer #2 Full Legal Name: Have yu ever participated in the SWIM Acrss the Sund? Yes N If yes, when? What is yur persnal fundraising gal? (The minimum fundraising cmmitment is $3,500) $ What made yu interested t participate in the SWIM? Are yu swimming in hnr f smene? Any ther infrmatin yu wuld like t share? Tw-Persn Relay Applicatin - Swimmer #2 Page 5 f 8

20 SWIMMER #2 TWO-PERSON RELAY APPLICATION - SWIMMING BACKGROUND Swimmer #2 Full Legal Name: Each Tw-Persn Relay applicant must have cmpleted a fur-hur r lnger qualifying swim. Prf must be submitted by the dcumentatin deadline. PLEASE LIST SOME OF YOUR MOST RECENT OPEN WATER EVENTS: (attach dcumentatin) Event Name: Lcatin/Distance: Date: Finishing Time: Water Temp: Winner Finish Time: What was yur place? Event Name: Lcatin/Distance: Date: Finishing Time: Water Temp: Winner Finish Time: What was yur place? Event Name: Lcatin/Distance: Date: Finishing Time: Water Temp: Winner Finish Time: What was yur place? Event Name: Lcatin/Distance: Date: Finishing Time: Water Temp: Winner Finish Time: What was yur place? OPEN WATER SWIMS PLANNED FOR CURRENT YEAR: Swim #1 Lcatin: Distance: Swim #2 Lcatin: Distance: Swim #3 Lcatin: Distance: OTHER ATHLETIC ACHIEVEMENTS: PHOTO: Please a high-reslutin (300 dpi) pht f yurself t Debrah.Cx@stvincents.rg alng with yur first and last name. We may use this fr the lcal media and prmtinal materials. Tw-Persn Relay Applicatin - Swimmer #2 Page 6 f 8

21 SWIMMER #2 QUALIFYING SWIM LOG - PAGE 1 USE FULL LEGAL NAMES (NO NICKNAMES OR ABBREVIATIONS). Swimmer #2 Name: Date: Start Time: START: Air Temp and Cnditins: Water Temp and Cnditins: Swimmer s Mental and Physical Cnditins: Feeding Schedule (Interval/Liquid Type/Gel): Lcatin f Swim: Observer: Finish Time: ACTUAL TIME: HOUR 1: Air Temp and Cnditins: Water Temp and Cnditins: Swimmer s Mental and Physical Cnditins: Feeding: Strke rate per minute: ACTUAL TIME: HOUR 2: Air Temp and Cnditins: Water Temp and Cnditins: Swimmer s Mental and Physical Cnditins: Feeding: Strke rate per minute: ACTUAL TIME: HOUR 3: Air Temp and Cnditins: Water Temp and Cnditins: Swimmer s Mental and Physical Cnditins: Feeding: Strke rate per minute: ACTUAL TIME: Tw-Persn Relay Applicatin - Swimmer #2 Page 7 f 8

22 SWIMMER #2 QUALIFYING SWIM LOG - PAGE 2 Swimmer #2 Full Legal Name: HOUR 4: Air Temp and Cnditins: Water Temp and Cnditins: Swimmer s Mental and Physical Cnditins: Feeding: Strke rate per minute: ACTUAL TIME: Ttal time f the Swim COMMENTS: Tw-Persn Relay Applicatin - Swimmer #2 Page 8 f 8