Rugby Clinic: Celebrating Women's Rugby & Title IX

We look forward to seeing you:

Saturday, June 22, 2024

7:30 am Checkin, 8:00 am Start, 12:30 End

@ Trimble Technical HS, 1003 W Cannon St, Fort Worth 76104

Athletic Field & Parking is behind the school

Download the agenda of activites and learn a bit more about women's rugby and opportunities to play. We have a great morning of activiteis and information lined up for our female participants.

Athlete's Name*

First NameLast Name

Birth Date*

MonthDayYear

Sex / Gender*

MaleFemale

Athlete's E-mail*

example@example.com

Athlete's Phone Number*

School Name*

Chisholm Trail High School

School District*

Eagle Mountain Saginaw ISD

Grade (entering)*

Graduation Year / Class of*

Are you interested in organizing a rugby team at your school campus?*

Are you interested in learning about gender equity and Title IX?*

T-Shirt Size (adult sizes)*

* Must be present & participate to receive

Pizza Preference

Parent/Guardian Name*

First NameLast Name

Parent/Guardian's Relationship*

Parent Phone Number*

Parent E-mail*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact's Name*

First NameLast Name

Emergency Contact's Relationship*

Emer Contact Phone Number*

Alt. Phone Number

Please list any allergies, chronic illness, or medical conditions that could effect participation. (If none, enter "none" or "NA")*

If the athlete has a prescribed inhaler or EpiPen, please state and explain any instructions. (If none, enter "none" or "NA")*

Acknowledgement / Assumption of Ricks & Consent to Participate*

As the Custodial Parent and/or Guardian of the named athlete, I recognize and acknowledge that the possibility of sustaining a minor to serious injury, including concussion, fracture, permanent disability or death, always exists with participation in sports. I further recognize and acknowledge that participation in a contact/collision sport may increase their possibility and that this Clinic includes, but is not limited to, physical activities that may involve contact/collision interaction with other persons, such as tackling, during small and whole group sessions. In exchange for the acceptance of my child’s participation in the Clinic, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Texas Interscholastic Rugby Association, the Dallas Jackals, the facility ownership, and any other associated organizations, their respective officers, agents, representatives, sponsors and advertisers from any and all liability for injury, sickness, disability, paralysis or death that may arise out of traveling to, participating in, or returning from the Clinic. In case of injury to said child, I hereby waive all claims against the aforementioned parties and, if applicable, owners and lessors of premises used to conduct Clinic activities. -- Furthermore, I recognize that there may not be a licensed medical professional available during the Clinic. To help reduce the risk of injury or illness, I agree to be solely responsible for the following: (1) my child has had a physical by a licensed physician to determine that he/she is fit to play a contact/collision sports such as rugby prior to participation; (2) my child has medical insurance coverage with no policy restrictions on or exclusion for participation in sport activities; (3) my child has a fitted mouthpiece / mouthguard for contact activities; (4) my child brings plenty of water to stay hydrated; (5) my child removes any external jewelry and nails are trimmed short; and, (6) my child understands he/she must abide by all coaching and referee instructions as well as Clinic rules. -- I ACKNOWLEDGE & ASSUME THE RISKS of PARTICIPATION as well as MY RESPONSIBILITIES TO HELP REDUCE INJURIES and therefore FREELY GIVE CONSENT FOR MY CHILD'S PARTICIPATION IN THE CLINIC.

Medical Release and Authorization*

As the Custodial Parent and/or Guardian of the named athlete, I hereby authorize the volunteer staff of the Clinic and/or onsite athletic trainer (if available) to provide preventative care and/or first-aid care to my child to prevent further injury or illness that may occur during participation. -- In the event of an emergency arising out of serious injury / illness, I also authorize the diagnosis and treatment of my child by any qualified and licensed medical professional onsite, which in the opinion of the attending medical personnel, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. -- If transported to a medical facility, permission is further granted to the attending physician and medical staff where my child is transported to proceed with any medical or minor surgical treatment, x-ray examination and medications for the said child. I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. -- This release is authorized and executed of my own free will, with the sole purpose of authorizing reasonable preventative care and medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence and shall be in effect on the date(s) and duration of the Clinic.

Media Release*

By participating in the Clinic, I consent to the photographing and videographing of my child by persons representing the Texas Interscholastic Rugby Association, Dallas Jackals, any other associated organizations and the media. I grant these named entities the right to use images of my child in all forms for all purposes, including any advertising, trade or commercial purpose, and I waive all royalty and compensation rights.

I have read and agree to the terms and conditions as set forth in this registration form. 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. I further attest that I am the custodial parent / guardian named in this document.*

Celebrating Women's Rugby & Anniversary of Title IX

WELCOME

ATHLETE INFORMATION

PARENT / GUARDIAN INFORMATION

EMERGENCY INFORMATION

ACKNOWLEDGEMENTS / RELEASES / CONSENT