English sign up sheet for the Phocas Introduction

Initials

First name

Infix

Last name

Gender
ManWoman

Date of Birth (DD-MM-JJJJ)

E-mail

Phone number

Steet and house number

Zip code and city

Study

Student number

Institution
Radboud UniversiteitHANOther

Do you have any allergies? Please let us know: ICsecretaris@nsrvphocas.nl

Sports history

Which sports did you practice?
RowingAthleticsCyclingIce skatingSoccerTennisVolleyballSwimmingBasketballHockeySomething else

Something else:

How many years have you practiced this sport?

How often did you practice per week?
Less than two times a week2 times a week3 times a week4 times a week5 times a weekMore than 5 times a week

What is your best sports performance? And in what year was that?

Have you practiced rowing before? And if so, at which club?

How many times a week would you like to row?
1 - 2 times a week2 - 3 times a week3 - 4 times a week4 or more times a week

Do you have any interest in becoming a coxswain?
YesNoI don't know

Length (in cm)

Weight (in kg)

Authorization

I hereby authorize the Penningmeester of N.S.R.V. Phocas to withdraw the amount of €32,50 from my bank account to pay for the Phocas introduction month. It is possible to decline this authorization by sending an e-mail to ICsecretaris@nsrvphocas.nl no later than the 30th of August.

IBAN

Name

Date (DD-MM-JJJJ)