Event date *

or first date in window

MM

DD

YYYY

Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Cell phone *

(Something you'll bring with you the day of the swim.)

(###)

###

####

Home address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Miscellaneous safety and comfort gear

WA Boater Education card

Horn or Whistle

Type IV throwable device

Fixed VHF radio

Handheld VHF radio

Fire extinguisher

Head

Emergency contact *

First Name

Last Name

Emergency contact phone *

(###)

###

####

Event understanding *

I have been selected by my swimmer to accompany them during the swim. I understand that I will be responsible for the safety of the swimmer and crew, navigation, and logistics before, during, and after the swim. I agree to follow all applicable laws related to operation of a vessel. A NOWSA observer will be on board during the swim to provide documentation only.

I understand the demands of this event.