Fall 2023 Loudoun Rugby Men's Registration

Athlete's Name*

First NameLast Name

Birth Date

Date

USA Rugby Member #*

E-mail*

example@example.com

Cell Phone*

Please enter a valid phone number.Format: (000) 000-0000.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Positions Played

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Emergency Contact Phone Number*

Format: (000) 000-0000.

Alt. Phone Number

Format: (000) 000-0000.

Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the athlete prescribed an inhaler? If yes, please explain any instructions.

Informed Consent and Acknowledgement I hereby give my approval for my participation in any and all activities prepared by Loudoun Rugby during the selected season(s). In exchange for the acceptance of said candidacy by Loudoun Rugby, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Loudoun Rugby, and all its respective officers, agents, and representatives from any and all liability for injuries arising out of traveling to, participating in, or returning from all Loudoun Rugby events. In case of injury, I hereby waive all claims against Loudoun Rugby, including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including rugby. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact your emergency contact in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach them. Permission is also granted to the Loudoun Rugby. and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of myself.

Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature*

Select only 1 registration type*

NEW PLAYER - 15's Fall Season Full Registration

Welcome to Loudoun Rugby's! This is for all new players to the club

$125.00

15's Fall Season Full Registration

Welcome BACK Loudoun Rugby players! This is for all returning players

$175.00

15's Fall Season Social Member Registration

This is a social club fee for players that just want to run at practices with the team.

$50.00

Total

$0.00

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