Mohawk College Athletics
Women’s Rugby 7’s Program
One Team…One Win
Relentless While We Do It!
Mohawk College
Department of Athletics and Recreation
Rugby Sevens Clinic Registration
First Name: _______________________________
Surname: ______________________________________
School: ___________________________________
Grade: ________________________________________
Club: _____________________________________
Address: __________________________________
City: _________________________________________
Postal Code: _______________________________
Phone: ________________________________________
Please check one or both:
I will be attending:
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Session #1 – Saturday, March 18th, 2017 1-4pm __________
Session #2 – Thursday, March 23rd, 2017 6-9pm __________
Release Form
In consideration of my participation in the Mohawk College Rugby Sevens Clinic, I hereby release,
waive and discharge the Mohawk College Department of Athletics and Recreation, any Mohawk
College staff or students, the Board of Governors of Mohawk College, any agents of Upright Canada
Rugby from any and all claims which I may have or may hereafter have against the College for
damages resulting from personal injury, losses or expenses of any kind, including, damages to property
arising out of or in any way related to my participation in the Mohawk College Rugby Sevens Clinics or
use of the David Braley Athletic and Recreation Center.
Photo/Video/Story Release Form
I give permission for Mohawk College to use any clinic participant’s name, story and/or photo/video
for print, electronic and visual use in perpetuity, to promote the College.
In signing this form, I realize that I will receive no remuneration for the above.
Parent/Guardian: _________________________________________ Date: _____________________________
(please print name)
Parent/Guardian: _________________________________________
(please sign)
PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)
First Name: _________________________________
Last Name: _________________________________
Date of Birth: (D/M/Y) _________________________
Address: _____________________________________
City: _______________________________________
Province: _____________________________________
Postal Code: ________________________________
Phone Number: _______________________________
Email: ______________________________________
In case of emergency please contact:
Contact Person 1
Name:_______________________________________
Relationship:_____________________________
Phone #: ____________________________________
Contact Person 2
Name:____________________________________
Relationship:_____________________________
Phone #: _________________________________
Please read carefully and check either YES or NO
1. Has your doctor ever said that you have a heart condition?
YES
NO
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2. Do you have chest pains brought on by physical activity?
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3. Have you developed chest pain at rest in the past month?
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4. Do you lose consciousness or lose your balance as a result of dizziness?
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5. Do you have a bone or joint (for example, back, knee or hip) problem that
could be aggravated by the proposed physical activity?
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6. Is your doctor currently prescribing medication for your blood pressure
or heart condition? e.g. diuretics or water pills
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7. Are you aware, through your own experience or doctor’s advice of any other
reason against your exercising without medical approval?
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8. Are you pregnant?
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If you have answered YES to one or more of the above questions, Mohawk College requires either a doctor’s
note or a note from parent/legal guardian giving permission for this athlete to participate in this event.
Parent/Guardian: _________________________________________ Date: _____________________________
(please print name)
Parent/Guardian: _________________________________________ (please sign)