7s - Hempfield-Penn Legacy Rugby Football Club Registration

Player Information Parent Information
First Name:
Last Name:
Address:
City:
State:
Zip:
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:
Address:
City:
State:
Zip:
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:
7s Registration Fee: $50. (Does not include PA Rugby fees)
Registration fee does NOT include shorts and socks. If you do not already have them the cost is an additional $35.00. Please select short size below:
Small     Medium     Large     X-Large     XX-Large
No uniform
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 .
Credit Card Information
First Name
:
Last Name
:
Street Address
:
City
:
State
:
:
 
:
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) :

Hempfield-Penn Legacy Rugby Football Club - CONSENT, WAIVER, AND RELEASE

I, the Player, or the Player named above (a minor), has my permission to participate in the Hempfield-Penn Legacy Rugby Football Club program.

I acknowledge (indicate one):
PLAYER IS OVER 18. The person executing this Waiver is the Player.
PLAYER IS UNDER 18. The person executing this Waiver is Player's parent or legal guardian.
PLAYER IS UNDER 13. The person executing this Waiver is Player's parent or legal guardian. Hempfield-Penn Legacy Rugby may/will not use any personally identifiable information of Player without express consent of Player's parent or legal guardian.

In consideration for Hempfield-Penn Legacy Rugby acceptance of Player's registration, and before participating in a Hempfield-Penn Legacy Rugby program or participating in any activity on a Hempfield-Penn Legacy Rugby owned/leased facility, I agree to the following on behalf of Player, myself, and my family:

  1. There are inherent risks in participating in the sport of rugby, including serious injuries and even death. These risks can happen, regardless of the level of care taken by the participant and/or the organizers.
  2. I knowingly and freely assume all risks of personal injury, property damage, or any other loss while participating in all activities related to Player's participation in the program, even if due to negligent behavior of Hempfield-Penn Legacy Rugby and/or its members, staff, club contractors and representatives, or officers.
  3. I agree that the Player will be bound by and comply with the rules and regulations of Hempfield-Penn Legacy Rugby and the program and will be subject to exclusion in the event of noncompliance, as determined necessary by Hempfield-Penn Legacy Rugby, in their sole discretion.
  4. I hereby authorize Hempfield-Penn Legacy Rugby officers and coaches, if after a reasonable attempt has been made to reach a parent, guardian, or emergency contact to obtain consent, or if sound medical practice decrees that there is not time to make such an attempt, to consent to any emergency medical treatment. I acknowledge that the registration and registration fee do not include accident insurance coverage. I agree to pay for any such treatment and to reimburse Hempfield-Penn Legacy Rugby for all costs and expenses.
  5. Intending to be legally bound, I hereby for myself and my family, heirs, and representatives waive and release Hempfield-Penn Legacy Rugby and their agents, representatives, organizers, affiliated organizations, sponsors, employees and associated personnel, including owners of fields or facilities, from any and all claims or rights to damages for injuries or losses suffered by the player, directly or indirectly, in training for, or traveling to and from, or participating in Hempfield-Penn Legacy Rugby related to any and all injury, disability, or death, whether arising from negligent behavior or otherwise, to the fullest extent permitted by law.
  6. I agree to allow Hempfield-Penn Legacy Rugby to photograph and video and use Player's likeness in any future promotional literature without compensation. FOR PLAYERS UNDER 13, pursuant to the Children's Online Privacy Protection Act ("COPPA"), I consent and authorize Hempfield-Penn Legacy Rugby to display my child's photograph or video on their websites and on the website of any third party with which Hempfield-Penn Legacy Rugby has a business relationship related to the program.
  7. I intend to provide as broad and inclusive a release of liability as permitted by law and if any portion hereof is held invalid, I agree that the remaining terms shall continue in full legal force and effect.

Concussion Release

Penn Legacy/UYSA Rugby Policy on Concussion Procedure and Protocol:
https://www.usarugby.org/concussions/

Go to this site and read the concussion fact sheet for parents/guardians:
https://assets.usarugby.org/docs/medical/return-to-play-protocols.pdf

Please read: Privacy Policy and Policy on Publication of Player Information on the Internet:
http://pennlegacy.org/images/PennLegacyPrivacyNotice.pdf

I have carefully read this consent and voluntarily agree to its terms and conditions.

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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