Hempfield-PennLegacy Rugby Football Club Registration
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.
|List any medical conditions or prohibitions player has (please include allergies) :
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.
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/: