Forms

This is only one of the many forms that will be available from this page.

 
  Union County Rugby High School Program
 Please Print and Fill Out This Registration Form


Spring 2004 Fee:
$50.00 per player.
$30.00 fee for returned checks.
Please return your application with check payable to
Union County Rugby Football Club:

Chris Clark
321 Monroe St., Apt 4
Hoboken, NJ 07030

Checks and applications received after xxxx, must include a $10.00 late fee
For more information, please call (201) 213-1952 or visit our website at www.mudturtlerugby.com

* Participants will only be allowed if a registration form is completed for each incumbent.
  


Child's Last Name:
 ___________________________________________
First Name:
 ___________________________________________
Address:
 ___________________________________________
City:
 ___________________________________________
State:
 ________
Zip Code:
 ___________________________________________
Home Phone:
 (______) ______ __________
e-mail:
 ___________________________________________
Gender:
 Male ____ Female ____
Shirt (circle):
 youth L | adult S M L
School:
 ___________________________________________
Grade in Sept. 2003:
 ____________________

* Please indicate if your child has difficulty with the symptoms listed below:

Heart Problems
Shortness of Breath
Asthma
Diabetes
Kidney Problems
Vision Problems
Chest Pains
Hearing Impaired

Glasses, Contacts
 Concussions
Seizures
Headaches
Bone Joint
Skull Fracture
Past Operations
Allergies
Other: _________________________________


Please explain if any of the above were checked:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Does your child take medication in certain emergencies? ____________________________________
(If yes please provide the coach written instructions.)

Please indicate how you can help the Union Mudturtles this season
Training and certification will be provided for all volunteers!
Assistant Coach Team Parent Referee Photographer Equipment Game help

I, the parent or guardian of the player named above, do hereby give my permission in my absence for any necessary emergency medical treatment to be administered by a licensed physician. I also give my approval for his/her participation in all Union County Rugby Football Club (UCFRC) activities and assume all such risks and hazards incidental to participation. I absolve, indemnify and agree to hold harmless UCFRC and its programs, sponsors, coaches and other participant's from all such risks and hazards.


Parent/Guardian Signature ____________________________ Relationship __________Date __________

In case of practice cancellation or to advise you of schedule changes, please provide the following information:

Names of both Parent(s)/Guardian(s) (if applicable): __________________________________________

Daytime and/or Work Phone #'s: ____________________

Email address: _________________________


For Union Rugby use only

Check Amount : $________ Check #: ______________ Cash Amount: $_______