Swimming Requirement Form
Cascadilla Boat Club, ltd. - PO Box 4032 - Ithaca, NY, 14850
Boathouse Phone 607-273-1167
Name ___________________________________________________ Date _________________

Address _______________________    City ____________ State ________  Zip ______

Signature ___________________________    Date of last swim test________________

Every 5 years members must provide evidence of demonstrated ability to:
  1. Tread water for 5 minutes, then
  2. Swim 200 yards unassisted within 20 minutes.
Indicate below how you meet this requirement
A. Passed a Swim Test taken at:________________________________________(pool location)
Date____________________________________

Signature of Lifeguard__________________________________________

B. I hold the following American Red Cross Certificates: (attach copies)
  • ________________________________________________
  • ________________________________________________
  • ________________________________________________

C. I am a current member of a formal swim team at:
Organization: ________________________________ Location: _______________

My event(s) is/are: __________________________________________________

My coach(es) is/are: __________________________________________________

D. My physical limitations prevent me from swimming. I therefore agree to wear an adequate floatation device at all times while participating or to be under the direct supervision of an A.R.C. certificated water safety personnel during all my activity at CBC.

(signed) ___________________________________________ date ______________