Panther Rugby Academy Coach Registration
Name
*
First Name
Last Name
USA Rugby ID Number
*
You must be a USA Rugby Member to participate as a coach in all PRA Events.
What level Rugby Coach are you?
Legacy 100
World Rugby Level 1 (Legacy 200)
World Rugby Level 2 (Legacy 300)
World Rugby Level 3 (Legacy 400)
None of the above
Please list your coaching experience.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email (list an email you check often)
*
example@example.com
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Instagram ID
@exampleID
What is your desired coaching focus?
Please Select
U23 Men
HS Boys
HS Girls
MS Youth
Shirt Size
*
Please Select
XSmall
Small
Medium
Large
XLarge
2XL
3XL
The above sizes are Adult Unisex
Current Rugby Club
Emergency Contact
First Name
Last Name
Emergency Contact Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Medical History
If the answer to any of the following questions (below), is yes, please describe the problem and its implications for proper first aid treatment.
Do you have any allergies or medical conditions that we need to be aware of?
Yes
NO
Please explain allergies:
Please explain medical conditions:
I have read, understand and agree to comply with the Waivers as outlined above.
*
Yes
No
Confirmation Signature
*
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Submit
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