Solo Swimmer Application

Transcription

1 The St. Vincent s SWIM Across the Sound Marathon Saturday, August 1, 2009 Captain s Cove Marina Bridgeport, CT Solo Swimmer Application Sponsored by: St. Vincent s Medical Center Foundation (203)

2 SWIM MARATHON RULES & GUIDELINES SOLO SWIMMERS 1. CLOTHING: One suit, swim cap, goggles, earplugs and grease will be allowed. For women, suits that cover up to their neck and down to their knees are acceptable. For men, suits may not cover their torso, nor go below their knees. Neither men nor women may wear suits that cover their shoulders in any way. All suits must be of the traditional swimming style lycra type suits. Solo swimmers must wear event swim cap provided. 2. ASSISTANCE: Solo Swimmers may not use flotation aids, propulsion devices, or any other devices to maintain body heat. Wetsuits, fins, hand paddles, pull buoys or boards are strictly prohibited. Pacing, drafting and towing are not allowed. Swimmers may not touch the escort boat or any other boat during the event. A violation of this rule shall result in disqualification. All solo swimmers should bring at least one crew member to provide feeding assistance. If a swimmer is unable to bring their own crew, please notify the race committee and we will use our best efforts to provide you a crew member. Swimmers are required to bring their own food for the swim. The use of alcohol or drugs is strictly forbidden. 3. QUALIFYING SWIM: All solo applicants must submit proof of a six-hour or longer qualifying swim in open water completed within the past 18 months in order to be eligible to participate in the event. Swimmers who have successfully completed any of the following swims within the past 18 months are exempt from the sixhour qualifier swim: Tampa Bay 24 mile Marathon Swim Manhattan Island Marathon Swim SWIM Across the Sound English Channel Catalina Island Round Jersey Swim (Channel Islands) Other USA/USMS distance swim > 10 miles 4. AGE MINIMUM: Solo swimmers must be 19 years old on or before December 31 of the year of the event, in accordance with FINA Age Rules. Exceptions may be considered under the discretion of the Event Committee. 5. MEDICAL EXAMINATION: All solo swimmers must have their primary physician fully complete the required medical form. Solo Application - Page 1 of 10

3 SOLO SWIMMER APPLICATION Full Legal Name: Address: City, State, Zip, Country Home Phone: PERSONAL INFORMATION Please Note: Use full legal names (no nicknames or abbreviations). Cell Phone: Contact Gender: DOB: (mm/dd/yy) Age: T-shirt size: Height: Weight: Please note: your name, age, hometown and background information may be used for media relations and promotional purposes. Your contact information may be used to reach you for media inquiries, but will never be published without your granted consent. WORK INFORMATION Occupation & Title: Employer: Employer Address: City, State, Zip Country Phone: Fax: Does Your Employer Match Charitable Donations? Yes No EMERGENCY CONTACT INFORMATION Name: Home Phone: Relationship: Cell Phone: Solo Application - Page 2 of 10

4 SOLO SWIMMER APPLICATION ACCIDENT AND RELEASE OF LIABILITY WAIVER I acknowledge that this 25km athletic event is an extreme test of a person s physical and mental limits and hereby certify that I am physically fit and have not been otherwise informed by a physician. I acknowledge that I am aware of all of the risks inherent in Open Water Swimming (training and competition), including possible permanent disability or death, and agree to assume all those risks. I acknowledge that this Accident and Release of Liability Waiver will be used by the event holders, sponsors and organizers of the event of the SWIM Across the Sound, and that it will govern my actions and responsibilities 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 addition, I also agree to abide by and be governed by the rules established by the Race Committee. Finally, I specifically acknowledge that I am aware of all the risks inherent in open water swimming and agree to assume those risks. Print Swimmer s Full Legal Name Age Signature Date If Swimmer is under the Age of 18, Signature of parent or guardian is also required. Print Parent/Guardian Name Age Signature of Parent or Guardian Date Solo Application - Page 3 of 10

5 SOLO APPLICATION - CREW INFORMATION Swimmer Full Legal Name: CREW #1 Name: City, State, Zip Work Phone: Is Cell available on race day? Relationship/Age: Address: Phone: Cell Phone: T-shirt Size: CREW #2 (ALTERNATE) Name: City, State, Zip Work Phone: Is Cell available on race day? Relationship/Age: Address: Phone: Cell Phone: T-shirt Size: Solo Application - Page 4 of 10

6 SOLO APPLICANT - QUALIFYING SWIM All solos applicants must submit proof of a six-hour or longer qualifying swim in open water completed within 18 months of the event to be eligible to participate. Number of marathon swims Qualifying Swim Tampa Bay 24 mile Marathon Swim Manhattan Island Marathon Swim SWIM Across the Sound (solo) English Channel Catalina Island Round Jersey Swim Other USA/USMS distance swim (>10 miles) Six-hour Qualifying Swim* Time - Date (please enter Pending if not completed at time of application) * Please complete and submit the Qualifying Swim Observer Report and Qualifying Swim Log. Solo applicants must submit this requirement by July 6, Six-hour Qualifying Swim should be six hours of continuous swimming, with in-water feedings (if at all possible) to try to duplicate the routine you will encounter in SAS. You should try to have a few people with you in order to assist in this qualifying swim so they can keep your log and help you with the feedings. You may also have other swimmers accompany you on this swim and can go as fast or slow as you desire. An example of a qualifying swim log is enclosed in this packet. After completion of your qualifying swim, your observer should submit the form below on your behalf. If you are exempt from a Six-hour Qualifying Swim, please submit copies of official race results or other documentation from one of the other events above. OBSERVER NAME: ADDRESS: PHONE / QUALIFYING SWIM - OBSERVER REPORT I, attest that swam continuously for six hours on, at beach located in the city of in the state of. Based upon this swim, I believe he/she is qualified to compete in the SWIM Across the Sound. I have attached a log from his qualifying swim. Signed Signature Solo Application - Page 5 of 10

7 SOLO APPLICATION - MEDICAL FORM Swimmer Full Legal Name: DOB: Parts 1 & 2 must be completed and enclosed with your application. INCOMPLETE MEDICAL FORMS WILL CAUSE YOUR APPLICATION TO BE DELAYED OR REJECTED. If you answer yes to any questions, you must provide an explanation on the back of this form. PART I: MEDICAL HISTORY (to be completed by Swimmer) 1. Have you ever suffered at any time from the following: a. Ear trouble, earache or deafness? YES NO b. Sinus trouble? YES NO c. Chest disease, including asthma, bronchitis, TB, collapse lung? YES NO d. Blackouts or fainting? YES NO e. Nervous disorders, concussions? YES NO f. Anxiety, nerves or nervous breakdowns? YES NO g. Heart Disease? YES NO h. High Blood Pressure? YES NO i. Diabetes? YES NO 2. Do you regularly or frequently take medications with or without prescription? YES NO 3. Are you currently receiving medical care or consulted a doctor in the last year? YES NO 4. Have you ever failed a medical exam or been refused life insurance? YES NO 5. Have you been to the hospital in the last year? YES NO 6. Do you smoke or use illegal drugs? YES NO 7. Do you have any allergies to medication? YES NO 8. Do you have any orthopedic problems? YES NO I certify that to the best of my knowledge, I am in good health and that I have not omitted any information which may be relevant to my fitness to swim. I authorize my medical doctor to disclose any detail of my past or present medical history if requested to do so by the SWIM race committee or application review panel. Signed: Date: PART II: DOCTOR S EXAMINATION The above named swimmer wishes to be examined to determine his/her physical fitness to participate in a 25km SWIM Across Long Island Sound. Please note that this is an extreme test of physical and mental endurance. Height: Weight: Blood Pressure: Pulse: Ears: R. Drum: R. Canal: L. Drum: L. Canal: Sinuses: Nose: Throat: Chest: Cardio Sys: Nervous Sys: Joints: Limbs: ECG: Urine-Albumin Urine-Glucose: NOTE: The Swim encourages and welcomes swimmers with disabilities. REMARKS: Any remarks about the swimmers physical condition should be written on the back of this form. AFTER EXAMINATION, I CONSIDER (print swimmer name) TO BE FIT or UNFIT to participate in this SWIM. Examining Doctor Print Name SIGN DATE Solo Application - Page 6 of 10

8 SOLO APPLICATION - PERSONAL STORY Swimmer Full Legal Name: Have you ever participated in the SWIM Across the Sound (SAS)? Yes No If yes, when? What is your personal fundraising goal? (The minimum needed to fundraise by a SAS Solo Swimmer is $1,500) $ What made you interested to participate in SAS? Are you swimming in honor of someone? Any other information you would like to share? Solo Application - Page 7 of 10

9 SOLO APPLICATION - SWIMMING BACKGROUND Full Legal Name: Each solo swimmer applicant must have completed a six hour or longer qualifying swim. Proof must be submitted by July 6, PLEASE LIST SOME OF YOUR MOST RECENT OPEN WATER EVENTS: (attach documentation) Event Name: Location: Date: Finishing Time: Water Temp: Winner Finish Time: What was your place? Event Name: Location: Date: Finishing Time: Water Temp: Winner Finish Time: What was your place? Event Name: Location: Date: Finishing Time: Water Temp: Winner Finish Time: What was your place? Event Name: Location: Date: Finishing Time: Water Temp: Winner Finish Time: What was your place? OPEN WATER SWIMS PLANNED FOR CURRENT YEAR: Swim #1 Location: Distance: Swim #2 Location: Distance: Swim #3 Location: Distance: OTHER ATHLETIC ACHIEVEMENTS: PHOTO: Please attach a passport style photo to your application. We may use this for the local media and promotional materials. Solo Application - Page 8 of 10

10 QUALIFYING SWIM LOG - PAGE 1 PLEASE NOTE: USE FULL LEGAL NAMES (NO NICKNAMES OR ABBREVIATIONS). Swimmer Name: Date: Start Time: Location of Swim: Observer: Finish Time: START: Feeding Schedule (Interval/Liquid Type/Gel): HOUR 1: HOUR 2: HOUR 3: Solo Application - Page 9 of 10

11 QUALIFYING SWIM LOG - PAGE 2 Swimmer Full Legal Name: HOUR 4: HOUR 5: HOUR 6: Total time of the Swim COMMENTS: Solo Application - Page 10 of 10