RUF ANNUAL PLAYER REGISTRATION

School Year

Ex. 2022-2023

Player Name

First NameLast Name

Player Name

First NameLast Name

Player Name

First NameLast Name

Player Name

First NameLast Name

Player Name

First NameLast Name

Player Date of Birth

Date

Player Date of Birth

Date

Player Date of Birth

Date

Select One

MaleFemaleOther

Age of Student on Last Birthday

Grade for Current School Year

Player Email

Player Address

Home or Main Cell Contact Phone #

Fall Sport(s)

Winter Sport(s)

Spring Sport(s)

Father or Guardian 1 Name

First NameLast Name

Father or Guardian 1 Name

First NameLast Name

Father or Guardian 1 Name

First NameLast Name

Father or Guardian 1 Name

First NameLast Name

Relationship

Father or Guardian 1 Phone #

Father or Guardian 1 Email

Father or Guardian 1 Address

Mother or Guardian 2 Name

First NameLast Name

Mother or Guardian 2 Name

First NameLast Name

Mother or Guardian 2 Name

First NameLast Name

Mother or Guardian 2 Name

First NameLast Name

Relationship

Mother or Guardian 2 Phone #

Mother or Guardian 2 Email

Mother or Guardian 2 Address

Emergency Contact 1: Name/ Phone #/ Relationship/ Address

Emergency Contact 2: Name/ Phone #/ Relationship

Player Allergies

Player Health Condition(s) of which Medical Personnel should be aware. Does Player where contacts/glasses? Have asthma/diabetes?

Player Health Condition(s) of which Medical Personnel should be aware

Player Prescription Medication(s) and for what they are being prescribed

Family Physician Name

Family Physician Phone #

Family Physician Address

Dentist Name

Dentist Phone #

Medical Insurance Carrier

Policy Number

Group Number

Subscriber Name

First NameLast Name

Subscriber Name

First NameLast Name

Medical Insurance Carrier Phone #

Medical Insurance Carrier Address

Preferred Hospital

USA ULTIMATE MEDICAL AUTHORIZATION

Purpose: To enable parents or guardians to authorize the provision of emergency treatment for their children who are injured or become ill while under the authority of the Radnor Ultimate Frisbee Club in the event the parents or guardians cannot be reached. This acknowledges that I (we), the parent(s) or legal guardian(s) of Player, recognize the potentially hazardous nature of the sport of ULTIMATE that an injury might be sustained. These injuries include but are not limited to PERMANENT, DISABILITY, BLINDNESS, PARALYSIS AND DEATH. In the event of such an injury to my child and we (I or my spouse or guardian) cannot be contacted, we give permission to qualified and licensed EMTs, physicians, paramedics, and/or other medical or hospital personnel to render such treatment.

We (I) release USA Ultimate, its employees, its agents, its volunteers, and its assigns from any personel injuries caused by or having any relation to the activity. We (I) understand that this release applies to any present or future injuries or illnesses and that it binds my heirs, executors, and administrators.

This release form is completed and signed of my own free will and with full knowledge of its signficance. I have read and understand all of its terms.

RTSD PERMISSION FROM PARENT, GUARDIAN FOR MEDICAL TREATMENT

As a parent/guardian I expect every effort will be made to contact me in order to receive my specific authorization before any treatment or hospitalization is undertaken. In the event of an emergency requiring medical attention, I grant permission to a physician or other hospital personnel designated by the Radnor coaching staff to attend my son/daughter.

PHUEL PLAYER EMERGENCY MEDICAL TREATMENT AUTHORIZATION

I hereby give my consent to have an athletic trainer, coach, team manager, emergency medical technician, nurse, medical treatment facility, and/or doctor of medicine or dentistry or associated personnel provide the applicant/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I understand treatment for injury will be based on information provided herein. I hereby authorize emergency transportation of the applicant/participant to a medical treatment facility should an individual listed above consider it to be warranted. I, the undersigned, do hereby release the RADNOR ULTIMATE FRISBEE CLUB, RADNOR HIGH SCHOOL, and PHUEL, their boards, employees, teams, officers, coaches, and referees, as well as any organization that holds any tournament that my child may participate in (RELEASED PARTIES) from any claims arising from personal injury, no matter how caused, which may occur to my child during his/her participation in the program, and/or tournaments and games. In addition, I hereby waive any claims, suits, actions, or causes against RELEASED PARTIES for tournaments, scrimmages, and/or practice sessions. I further agree to indemnify and hold forever harmless the RELEASED PARTIES against all losses, including counsel fees and court costs, from any and all claims made against it by any party as a result of my child's actions, negligent or intentional, which may result in injury or loss to another participant, spectator, or other person.

Parent/Guardian Name

Relationship to Player

Parent/Guardian Signature*

Parent/Guardian Signature

Date

Parent/Guardian Phone #

Parent/Guardian Email