Participant's Name
*
First Name
Last Name
Date of Birth
*
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DD
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Shirt Size
*
Small
Medium
Large
X-Large
XX-Large
XXX-Large
Best email address
*
Best Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Participant Type
*
Please check all that pply
Registered with USA Rugby
*
US participants should be registered with the national governing body, USA Rugby
Team
*
How did you hear about US Collegiate Development?
Please check all that apply
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone 1
*
Country
(###)
###
####
Emergency Contact Phone 2
*
Country
(###)
###
####
Doctor's Name
*
First Name
Last Name
Doctor's Phone
*
Country
(###)
###
####
Participant's Health Insurance Provider
*
Health Insurance Policy Number
*
Health Insurance Group Number
*
Medications (including inhalors)
*
List Medications
List allergies or special needs
List injuries that have occured in last 6 months
MY WAIVER EXPRESSLY MEANS THAT:
*
ACKNOWLEDGEMENT:
*
MEDIA RELEASE:
*
SIGNATURE (PARENT’S/GUARDIAN’S IF UNDER 19)
*
I agree to this electronic signature. Type "/" then full legal name, then "/" again:
Date
*
MM
DD
YYYY
Name
*
First Name
Last Name
