Junior-Side Club Rugby Athlete Registration - rev 2020

Junior-Side Club Rugby
Athlete Registration
Make sure all information is correct and complete. Incorrect or partial information may void your registration and will effect your abilitiy to participate. Your registration is not complete until all required forms and payment is received.

REGISTRATION MUST BE COMPLETED BY / WITH A CUSTODAL PARENT or LEGAL GUARDIAN. This also applies to participants who are age 18 and financially supported by a parent or guardian.

Athlete & Parent Information
Athlete's Legal Name *

First Name Middle Name Last Name
Sex/Gender *
Birth Date *

Month Day Year
Age on Sept 1st *
Current School Year
Athlete's Height *
Athlete's Weight *
Athlete's Mobile Phone *
Athlete's Email Address *

Confirmation Email Please Confirm
School *
Grade *
Current School Year
Was the athlete CIPP'd with USA Rugby last year *

Yes No
If Yes, USA Rugby CIPP #
With What Club?
Parent's / Guardian's Name (primary contact) *

Prefix First Name Last Name
Relation to Athlete *
Parent's Mobile Phone *
Parent / Guardian Email Address *

Confirmation Email Please confirm
Emergency Contact Name *

Prefix First Name Last Name
Relation to Athlete *
Emergency Contact Phone *
Athlete's Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code