Middletown CT Recreation
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Crew Waiver

Central Connecticut Rowing
Swimming Certificate
Participant’s Name:____________________________________________________________
Participant’s Address:__________________________________________________________
Phone 1:_____________________________
Note to Lifeguard or Water Safety Instructor
The above named rower plans to participate in the City of Middletown sponsored rowing program. Please supervise the participant as they perform the required swim test at the facility in which you work. If the above-named individual passes the swim test identified below, please sign the certification and give it to the participant to return to the head coach.
Thank you for your assistance.
Certification by Lifeguard or Water Safety Instructor
I certify that I personally observed the above named participant swim a distance of 100 yards without the aid of any propulsion device such as fins or other aids and without the use of any floatation device and without resting on the side of the pool or any other support. I also observed the named participant to tread water/float for 10 minutes, likewise without aid, support or use of floatation devices. At the end of the swim and tread/float, the above named participant was able to put on a lifejacket while floating.
Test performed at (name of pool):________________________________________________
Date test performed:_________________________
Lifeguard/WSI signature:________________________________________________________
Lifeguard/WSI Name (printed):____________________________________________________
American Red Cross Certification Number (if available):________________________________
City of Middletown
Recreation and Community Services Department
61 Durant Terrace
Middletown, CT 06457