Rugby League Registration Form

Player Name

First NameLast Name

Are you over 18 ?

YesNo

Guardian / Parents Names

First NameLast Name

Address

Street Address

Street Address Line 2

City

Postal / Zip Code

Home Phone

Cell Phone

E-mail

example@example.com

Rugby skill level

Interested in Volunteering while your team not playing?

Match RefereeOperate Scoreboard

I would like to play on the same team with following players. League/Team organizers will form teams base on this buddy list and your skill level.

Important Notes

· Dress appropriately.

· No food or drink in the field.

· Keep the field clean.

· The league/team organizers reserve the right to form the teams to ensure the talents of all teams are balanced.

· Fee: refer to the website

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Do you have health insurance ?

YesNo, I'll pay with cash.

Insurance Carrier

Name of Policy Holder

Subscriber ID/Group Number

Card Number / Card Date

Do you have any allergies, chronic illness, or medical conditions that would limit high level activtiy?

YesNo

Please describe

Name of Physician / Emergency Medical Care Facility

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

I have read and agree with the above conditions

YesNo

Confirmation E-mail

example@example.com

Signature

After completing this form, please click Submit Form. You will receive a confirmation email. If you do not receive the email within a few minutes, please check your spam; otherwise, please contact us at info@example.com.

Rugby League Registration Form

Athlete Information

Emergency Contact & Health Insurance Information

Parental Permission For Emergency Treatment

Release of Liability