Scholastic Rugby Athlete Registration

Scholastic Rugby Conference
Athlete Registration
School*
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's Legal Name*
  
  First NameMiddle NameLast Name
- Sex/Gender*
- Grade*
  Current School Year
- Birth Date*
  
  MonthDayYear
- Age on Sept 1st*
  Current School Year
- Athlete's Height*
- Athlete's Weight*
- Athlete's Mobile Phone*
  Format: (000) 000-0000.
- Athlete's Email Address*
  
  Confirmation EmailPlease Confirm
- Was the athlete CIPP'd with USA Rugby last year*
  
  YesNo
- If Yes, USA Rugby CIPP #
- With What Club?
- Parent's / Guardian's Name (primary contact)*
  
  PrefixFirst NameLast Name
- Relation to Athlete*
- Parent's Mobile Phone*
  Format: (000) 000-0000.
- Parent / Guardian Email Address*
  
  Confirmation EmailPlease confirm
- Emergency Contact Name*
  
  PrefixFirst NameLast Name
- Relation to Athlete*
- Emergency Contact Phone*
  Format: (000) 000-0000.
- Athlete's Home Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- As a custodial parent or legal guardian of the minor participant, I and my child understand that participation in rugby activities is a privilege not a right. In consideration for the privilege of participation in rugby activities governed by Panther City Rugby and other collaborating rugby clubs (herein after "Club Rugby"), I and my child acknowledge and agree to the following as indicated by a check.
- ACKNOWLEDGEMENT OF RISK*
  
  I and my child fully understand that Rugby, like all sports, involve risks and dangers of SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS AND DEATH (“Risks”). These risks and dangers may be caused by my or my child’s own actions or inactions, the actions or inactions of others participating in activities which include coaches, referees and/or spectators, the conditions in which a Rugby activity takes place (such as, but not limited to, exposure to adverse weather conditions and/or high altitude; flaws and defects in equipment and facilities; irregular field conditions; and negligent field maintenance, negligent officiating, negligent coaching and negligent participation) and/or the negligence of the “Releasees” named below.I and my child fully understand that there may be other risks and social and economic losses either not known to me or my child or not readily foreseeable at this time; and I and my child FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR THE LOSSES, COSTS, AND DAMAGES.I and my child understand the nature and dangers of Rugby activities.
- ASSUMPTION OF RISK*
  
  As a custodial parent or legal guardian, I am fully aware of my child’s athletic experience and physical capabilities and believe that he / she is qualified to participate in Rugby competitions and related activities. I further agree/warrant that if at any time I or my child believe conditions to be unsafe, my child will immediately cease further participation in the Rugby activity, report the issue to the coach or nearest administrator, and seek medical care as directed or indicated.I AND MY CHILD CONSENT TO PARTICIPATION IN RUGBY ACTIVITIES AND FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES incurred as a result of such participation.
- RELEASE & INDEMNIFICATION*
  
  I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS PANTHER CITY RUGBY AND OTHER COLLABORATING RUGBY CLUBS, AND ANY ORGANIZATION THEY MAY BE AFFILIATED WITH, along with their respective administrators, directors, agents, officers, volunteers, and employees, as well as other participants, any sponsors, advertisers, and, if applicable, owners and lessors of premises on which any activity takes place (each considered one of the “Releasees” herein) from all liability, claims, demands, losses, or damages on my or my child’s account caused or alleged to be caused in whole or in part by the negligence of the Releasees or otherwise, including negligent rescue operations and further agree that if, despite this release, I or anyone on my child’s behalf make a claim against any of the Releasees named herein, I WILL INDEMNIFY, SAVE AND HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY, DAMAGE OR COSTS THAT MAY BE INCURRED AS THE RESULT OF ANY SUCH CLAIM.
- CONSENT TO MEDICAL CARE*
  
  I and my child acknowledge that the “Consent to Medical Care & Questionnaire” must be fully completed and submitted electronically before the first “contact practice”. We understand that failure to submit these forms will forfeit the participant’s opportunity to practice and compete in contact activities. -- Click the link below to access the form.
- Consent to Medical Care & Questionnaire
- MEDICAL INSURANCE AGREEMENT*
  
  I acknowledge that is my responsibility to ensure that my child is covered by medical insurance that has a RECOMMENDED MINIMUM OF $100,000 IN MEDICAL COVERAGE, with NO RESTRICTIONS FOR ACCIDENTS WHILE PARTICIPATING IN SPORTS AND RELATED ACTIVITIES. I understand such insurance will be my primary source of payment should medical treatment be necessary as a result of my child’s participation in rugby related activities.I acknowledge that excess medical insurance may be available through USA Rugby for injuries that occur during participation in sanctioned rugby activities. I understand that such insurance is intended to supplement the primary medical insurance that I have secured for my child to help cover medical costs up to $10,000.I further acknowledge that "CATASTROPHIC INSURANCE" IS NOT AVAILABLE to provide financial support in the event of long-term or permanent disability.
- RELEASE OF LIABILITY FOR PUBLICITY OF IMAGE OR INFORMATION*
  
  I, the undersigned, recognize and accept that on occasion my child’s image, still or moving, my child’s name and other general personal profile data, may be used with respect to rugby activities through the printed, audio, video, or other electronic media, including the internet. I and my child give permission for use of such pictures and/or data and release Panther City Rugby and other collaborating rugby clubs, their Directors, Coordinators, Operators, Coaches, Sponsors and/or any other individual associated with them, from any liability resulting from the distribution of this information. I and my child waive all claims, both current and future, for compensation for such use and distribution.I and my child do not give permission for child's name, image, or likeness to be used, except where our image, still or moving, is captured in a public environment as part of a rugby related activity such as during a competition.
- CONSENT FOR USE OF PERSONAL INFORMATION*
  
  To determine eligibility status, I authorize Panther City Rugby and other collaborating rugby clubs to collect and use personal information about my child for the purpose of receiving communications from USA Rugby, Texas Rugby Union, Rugby Texas, and any collegiate rugby conference as well as any educational institution my child is enrolled in to verify registration with them.To communicate upcoming activities and changes to them, I authorize Panther City Rugby and other collaborating rugby clubs to contact me and/or my child via text message, email, or telephone.I understand that I may withdraw consent to collection, use or disclosure of my personal information at any time by contacting Panther City Rugby at President@PantherCityRugby.com or by mail at Panther City Rugby, PO Box 470066, Fort Worth, TX 76147.
- ACKNOWLEDGEMENT & AGREEMENT OF RULES*
  
  I and my child understand and agree to abide by all rules and regulations, including the arbitration procedures therein, for any dispute regarding my child’s eligibility or right to participate in, Rugby activities governed by USA Rugby, Panther City Rugby and other collaborating rugby organizations as set forth in the policies and rules of competition agreed upon by these organizations, and as they are amended on a periodic basis, which I and my child understand are available at www.USARugby.org and www.panthercityrugby.com/club-policies.
- AFFIRMATION OF ELIGIBILITY*
  
  I and my child affirm that he/she is not suspended or banned from play or participation by any club, local area union, territorial union, or national union, and we authorize Panther City Rugby and other collaborating rugby clubs to verify my child's status with the appropriate governing agencies. I and my child acknowledge that the aforementioned entities have the right to revoke my child’s registration and therefore eligibility to participate in Rugby activities, in the event of any violation of the aforementioned statement.
- GOVERNING LAW , VENUE, JURISDICTION*
  
  I and my child understand and agree that this document is intended to be as broad and inclusive as permitted under applicable law and shall be governed by Federal and Texas law. In the event of a dispute, the exclusive venue and jurisdiction for any lawsuit arising out of such dispute shall be the County and/or District Court(s) located in Tarrant County.
- SEVERABILITY*
  
  If any provision of this document is determined to be invalid for any reason, such invalidity shall not affect the validity of any of the other provisions, which other provisions shall remain in full force and effect as if this document had been executed with the invalid provision eliminated.
- AS THE NAME PARTICIPANT (ATHLETE), I hereby certify by my signature below that I have completely read and understand this registration document and its terms. Prior to signing this document, I have had the opportunity to ask any questions about the terms and conditions presented. I am aware, by signing this document, that I ASSUME ALL RISKS AND WAIVE AND RELEASE CERTAIN RIGHTS THAT I AND EACH OF MY HEIRS, NEXT OF KIN, FAMILY, RELATIVES, GUARDIANS, CONSERVATORS, EXECUTORS, ADMINISTRATORS, TRUSTEES AND ASSIGNS MAY HAVE AGAINST RELEASED PARTIES. THIS RELEASE SHALL BE EFFECTIVE AND BINDING UPON ME. I further represent that if I am under the age of 18 - or - I am age 18 and financially supported by a custodial parent or legal guardian such adult must also sign this document.*
  
  SIGNATURE OF PARTICIPANT (Athlete)
- I REPRESENT THAT I AM A CUSTODIAL PARENT/LEGAL GUARDIAN OF THE ABOVE NAMED and SIGNED PARTICIPANT, who is under 18 years of age - or - who is age 18 and financially supported by me. I HAVE READ THE ABOVE RELEASE AND AM FULLY AWARE OF THE CONTENTS THEREOF. IN CONSIDERATION FOR ALLOWING MY CHILD/WARD TO PARTICIPATE IN RUGBY ACTIVITIES, I HEREBY CONSENT TO THE TERMS AND CONDITIONS PRESENTED. ON BEHALF OF MY CHILD/WARD, WE ASSUME ALL RISKS AND WAIVE AND RELEASE CERTAIN RIGHTS THAT I AND MY CHILD/WARD MAY HAVE AGAINST RELEASED PARTIES. THIS RELEASE SHALL BE EFFECTIVE AND BINDING UPON ME, EACH OF MY HEIRS, NEXT OF KIN, FAMILY, RELATIVES, GUARDIANS, CONSERVATORS, EXECUTORS, ADMINISTRATORS, TRUSTEES AND ASSIGNS.*
  
  Signature Parent/Guardian (primary contact)
- When you press the submit button, you will receive an email confirmation that your registration was received. Please print for your records and retain as verification of completion.
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