Hempfield-PennLegacy Rugby Football Club Registration

Player Information Parent Information
First Name:
Last Name:
Phone: (999-999-9999)
Gender: Male:   Female:
Date of Birth: (mm/dd/yyyy)
Current grade in School:
Club/Team Played on Last Season:
Has registering player played rugby before? Yes     No
First Name:
Last Name:
If address is different than Player, please fill in address:
Phone: (999-999-9999)
Cell Phone: If no cell phone, then enter n/a.
Email Address:
Confirm Email Address:
If yes, please provide info regarding playing experience below:
Fees and Uniform Information:
Registration Fee: $150. (Does not include CIPP fees)
Registration fee includes shorts and socks. Please select short size below:
Small     Medium     Large     X-Large     XX-Large
Family Donations to the All Kids Play Fund:
    Supporter ($10)     Patron ($25)     Bronze ($50)     Silver ($100)     Gold ($250)     No
Each will be recognized on the “All Kids Play” Fund Thank-you Page on the website.
I wish to pay the above fees by credit card Or I will be mailing a check payable to Penn Legacy, PO Box 216, Landisville, PA 17538.
Credit Card Information
First Name
Last Name
Street Address
Expiration date
Emergency Information
Emergency Contact:
Emergency Phone:
Health Insurance Name:
Physician Name:
Physician Phone:
Health Insurance Policy #:
List any medical conditions or prohibitions player has (please include allergies) :
Parent's/Guardian's Consent
The above player has my permission to participate in the Hempfield-Penn Legacy Rugby Football Club program. In consideration of your acceptance in enrollment, I, the player, and we, the parents/guardians, individually, collectively, intending to be legally bound, hereby for ourselves and our heirs, executors and administrators, waive and release the Hempfield-Penn Legacy Rugby Football Club and the Hempfield Soccer Club, its agents and representatives, from any and all claims or rights to damages for injuries or losses suffered by, me the player, directly or indirectly, in training for, or traveling to and from, or competing in or while attending any future Hempfield-Penn Legacy Rugby Football Club functions. I acknowledge that the registration fee does not include any accident insurance coverage. I consent to medical treatment for my child in the event of an emergency.

I, the parent/guardian of the registrant, a minor, or adult registrant of legal age, agree that I and the registrant will abide by the rules of the Hempfield-Penn Legacy Rugby Football Club and its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with rugby and in consideration of the Hempfield-Penn Legacy Rugby Football Club accepting the registrant for its rugby programs and activities (the “Programs”), I hereby release, discharge, and/or indemnify the Hempfield-Penn Legacy Rugby Football Club, Mid-Atlantic Rugby Union, the Eastern Pennsylvania Rugby Union, the Lancaster Ruby Football Club, Roses Football Club, Hempfield School District and Hempfield Soccer Club, and their affiliated organizations and sponsors, their employees, board members and associated personnel, including the owners of fields or facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs, and/or being transported to or from the same, which transportation I authorize.

The Hempfield-Penn Legacy Rugby Football Club has a zero-tolerance policy of any use and abuse of all drugs, smoking, alcohol, and mood altering substances. Any player found smoking or using alcohol, drugs or mood altering substances during any rugby event or while traveling to and from any rugby event will be dismissed from the team. I, the player, accept the information and consequences as listed above.

Concussion Release

Penn Legacy/EPSYA Policy on Concussion Procedure and Protocol:

Go to this site and read the concussion fact sheet for parents/guardians:

Your electronic signature below (after the 'S/:' below) indicates that you have read and fully understand the Consent, Release, Policy and Concussion Release above and its terms, and consent to be bound.

Please enter your First and Last Name S/:

I also accept that the player is aware and accepts the Policy listed above.
Submit info then continue to print out registration form that will appear.
Please print 2 copies one to sign and submit by mail and one to keep for your records. Instructions are on form.

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