New York Rugby Club Youth & High School Program - Player Registration
*************ALL FIELDS ARE REQUIRED**************
PRINT CLEARLY
Player Name
__________________________________________________________
Email Address ___________________________________________________________
Address
___________________________________________________________
Include: Apartment number, Address, Street, City/Borough, Zip code
Cell Phone
___________________________________________________________
Include Area Code
Home Phone
____________________________________________________________
Date of Birth ______________________
Age & Grade as of Sept. 1, 2012 ______________________
Name of School ______________________________________________________________________________
Mother’s Full Name ________________________________________________________________________________
Mother’s Cell Phone _____________________ Mother’s E-mail Address _____________________________________
Include Area Code
Father’s Full Name _________________________________________________________________________________
Father’s Cell Phone ______________________ Father’s E-mail Address ______________________________________
Include Area Code
EMERGENCY INFORMATION
What is the best way to reach a parent in the event of an emergency?
__________________________________________________________________________________________________
Your Physician ____________________________________ Physician Phone __________________________________
Your Insurance Carrier _________________________ Your Insurance Policy Number ___________________________
Previous Injuries or Allergies that we should be aware of
__________________________________________________________________________________________________
If parents cannot be reached, please list 2 emergency contacts:
Name: ___________________________ Relationship:_______________ Cell Phone Number: _____________________
Name: ___________________________ Relationship:_______________ Cell Phone Number: _____________________
Are you eligible for free or reduced price lunch at school? (circle one):
(optional)
Household annual income for anonymous use on grant applications (circle one):
(optional)
yes
no
< $20,000
$20,000 - $30,000
$30,000 - $40,000
$40,000 - $50,000
$50,000 - $75,000
> $75,000
Number of people in household (optional): _________
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(rev. 6/13/13)
Agreement and Legal Waiver
1. New York Rugby Club Youth & High School Rugby Program has permission for my child to participate in all
programs, including field trips that are planned and supervised by New York Rugby Club Youth & High School
Rugby Program.
2. New York Rugby Club Youth & High School Rugby Program has the unrestricted right to terminate this
enrollment agreement at its sole discretion; such termination may be due to player behavior.
3. New York Rugby Club Youth & High School Rugby Program has permission to reproduce and publish any
photograph, video or likeness of my child for advertising, commercial or any lawful purpose.
4. New York Rugby Club Youth & High School Program has permission to communicate with my child directly
through social media and mobile technology to discuss program logistics and other information already conveyed
through email.
5. Player, and his/her custodial parent(s) and/or legal guardian(s) (together referred to as the “Undersigned”),
hereby consent to Player’s participation with the New York Rugby Club Youth & High School Rugby Program
(the “Team”). The Undersigned understand and agree that participation includes, but is not limited to practice
sessions, games, meetings, clinics, functions, parties, fund-raising, and the like, and transportation to and from
these activities. The Undersigned further understand and agree that transportation may be via private automobile
and that the drivers will include adults, other players, and students. The Undersigned understand that some
drivers may be underinsured or uninsured and the Undersigned agree to supplement their insurance to provide
for sufficient underinsured or uninsured coverage to compensate for any losses resulting from injury or death in
connection with a transportation mishap. The Undersigned otherwise waive claims against any driver beyond his
or her insurance coverage, as well as any New York Rugby Club Youth & High School Rugby Program coach or
staff, or against the Metropolitan New York Rugby Union and the Northeast Rugby Union officials and
administrators.
6. The Undersigned understands and agrees that the team is not sponsored by the New York City Public School
System, and as such, these institutions and their administrators and officials are not responsible or liable for
injury, sickness, disability, paralysis or death that may result from Players participation with the team. Thus all
claims against said entities and individuals are waived.
7. The Undersigned understand that there may not be a medical physician or trainer at the Team games or practice
sessions.
8. The Undersigned understand and agree to be solely responsible for the following:
A. To see that the Player has a physical to determine if he/she is able and fit to play rugby
B. To see that Player has appropriate medical insurance
C. To see that Player wears a mouthpiece during ALL team practices and games
D. To see that Player abides by all team rules, regulations and instructions
E. To see that player avoids the use of alcohol, tobacco, and controlled substance without a proper prescription
F. To see Player keeps his/her personal life clean and in accordance with laws and regulations
8. Permission to Treat and Transport: The New York Rugby Club Youth & High School Rugby Program has
permission to treat my child for routine and minor injuries such as scrapes and bruises. If a Certified Athletic
Trainer or other medical staff is present at the time of injury, I hereby give my permission to the New York Rugby
Club Youth & High School Program and its agents to consent to and allow treatment by medical staff, including
transportation via ambulance or personal vehicle to a hospital or other medical facility. In the event that a
parent, emergency contact or the family physician cannot be contacted in an emergency, New York Rugby Club
Youth & High School Rugby Program and its agents has my permission to give consent to any and all treatment
which a licensed physician, surgeon or medical practitioner may deem advisable.
9. The Undersigned individuals release the New York Rugby Club Youth & High School Rugby Program, and all
those associated with the New York Rugby Club Youth & High School Rugby Program from all responsibility with
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(rev. 6/13/13)
respect to personal or financial injury that may occur from participating as a member of the New York Rugby
Club Youth & High School Rugby Program. We understand the risks involved and we accept those risks. We
further state that we are properly insured against injury and have provided a copy of both sides of my child’s
insurance card and legal identification.
10. The Undersigned understand that players on the team may include players 20 years of age and younger, and that
the team will not only compete against and practice with other youth teams, but also against adult clubs and
college age teams.
11. As per USA Rugby Eligibility Regulations, the Undersigned agree to accept all responsibility and risks associated
with playing “College” or “Adult Rugby”, including front row positions, and acceptance of any associated risk of
playing with adults, who may be stronger and more physically developed than the player. The Undersigned
confirm that the player has an appropriate understanding of the physical attributes required of, and the risks to
players, playing “College” or “Adult Rugby”, including front row positions, and that the player has the requisite
skills and experience to play “College” or “Adult Rugby”, including front row positions.
12. The Undersigned understand that rugby is an exciting, rough, physical contact sport and that as, with all sports,
the possibility for injury, be it serious or minor, always exists. The Undersigned hereby accept the risks that
accompany participation. The Undersigned agree that they will not hold the Team, the coaching staff, the Rugby
Union, and it’s officials and administrators responsible for injury, sickness, disability, paralysis, or death that
may result from participation with the Team and all claims arising from such participation are waived.
13. * Release and waiver of liability: in consideration for player’s right to participate, the undersigned herby
release, discharge, and covenant not to sue * the coaches, the officials, and/or administrators of the New York
Rugby Club Youth & High School Rugby Program, the Empire GU, RugbyNY, and sponsors and workers. *The
undersigned agree that this release is binding**And effective as to themselves as well as to their personal
representatives, assigns, heirs, and next of kin and that it applies to any and all loss or damage claimed on
account of injury, disability, or death, whether caused by negligence or otherwise.
14. * The Undersigned understand by signing this release they are giving up substantial rights they would
otherwise have to recover damages for losses and they agree that they are doing so voluntarily and without
inducement, threat or duress. The Undersigned agree that they have had the opportunity to seek legal advice
before signing this release and have either done so or voluntarily elected not to and waive this opportunity.
15. The Undersigned agrees to annually enroll and maintain membership for the player in the USA Rugby’s
Membership Program, also known as “CIPP”.
16. The Undersigned agree to accept all responsibility. We have read and understand and agree to the information
and wavier and release of liability as set forth above.
______________________________________________________ Date ___________________________________
Player’s Name & Signature:
______________________________________________________ Date ___________________________________
Parent/Guardian’s Name & Signature:
______________________________________________________ Date ___________________________________
Parent/Guardian’s Name & Signature:
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(rev. 6/13/13)