Join/Register | Registration form |
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Cherry Creek Rugby Football Club Registration and Emergency Medical Consent to Treatment for a Minor Players Name_________________________________________ Age_____________ Gender_____________ Date of Birth___________ Ht_____ Wt______ Jersey Size_______ Email___________________________ Address____________________________________ City___________________________ Zip_____________ Home Phone_____________Student’s Cell Phone_________________ School________________ Grade____ List two people to contact in case of emergency: Second Adult Contact_________________ Primary Phone________________ Additional Phone___________ Important Information Medical Insurance Co___________________________________ Policy Number________________________ Are you allergic to any drugs______ If so, which_________________________________________________ Allergies?(bee stings, dust)___________________________ Do you have Asthma?_______ Diabetes?______ Have you ever had a concussion?______ If so, when?______________________________________________ Previous injuries _____ List of injuries and when they occurred______________________________________ I, __________________________(parent or guardian) of the city of_______________________in the county of__________________, Colorado, do hereby state that I am the natural parent or legal guardian having custody of ________________________, and minor/dependent, age________, born____________________. In connection with my child’s participation in rugby, I authorize any accompanying adult bringing my child to your treatment facility to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to the minor under the general or specific supervision, and on the advice of any physician or surgeon who is licensed to practice when the need for such treatment is immediate and when efforts to contact me are unsuccessful. I understand that I assume all liabilities and expenses for the above. I waive all claims against the above referred to adult, physicians, hospitals, and their employees, ambulatory care, etc. in connection with the decisions for such immediate care. Signed______________________________________________________________ Date___________________ Signed______________________________________________________________ Date____________________
Code of Conduct As a member of Cherry Creek Rugby Football Club I agree to abide by the following code and to actively promote the rugby tradition of sportsmanship at all times. My behavior and influence towards fans, coaches, teammates, opponents, and game officials will seek the highest standard. I understand that I and my club will be held accountable for both individual and group behavior and that of our fans. 1. I realize that Cherry Creek Rugby Football Club is not affiliated with Cherry Creek Schools but that my and our behavior will reflect on my club, my family and my community. 2. The use or possession of tobacco, drugs, including steroids, or alcoholic beverages in any form will not be tolerated regardless of quantity. Any violation occurring at any time during the present season may result in a suspension for the rest of the season from the Cherry Creek Rugby Football Club and from participating in the Colorado Youth Rugby League or the Touch Rugby Youth League. 3. The use of profane or abusive language is not acceptable and will not be tolerated. This includes directing language to opponents, coaches, game officials and spectators. Violation can result in placement in the “Sin Bin” as instructed by the Referee. Repeated offenses will result in my being sent out of the match and reposts being sent to the Eastern Rockies Rugby Football Union for disciplinary action including suspension from play. 4. I agree to abide by the Laws of the Game and the rules of its governing bodies. As the laws state in incidents of “foul play” i.e. fighting, taunting, or dangerous play, I will be subject to placement in the “Sin Bin: as instructed by the Referee. Repeated offenses will result in my being sent out of the match and reports will be sent to the Eastern Rockies Rugby Football Union for disciplinary action including suspension from play. AS THE PARENT OF________________________________________, I have read the above rules and I agree that my son/daughter will honor the rules, decisions and disciplinary process governing members of the Cherry Creek Rugby Football Club, Colorado Youth Rugby, the Eastern Rockies Rugby Football Union, and USA Rugby.
SIGNED_____________________________________ DATE_______________________ SIGNED_____________________________________ DATE_______________________
Waiver and Release of Liability By signing this form both the athlete and parent/guardian acknowledge that Rugby is a fast paced sport involving vigorous contact among players, during both games and the preparation for games (together hereinafter referred to as “rugby”), and that inherent in rugby are risks of significant physical injury, even paralysis or death. The athlete and parent/guardian represent that they have read this release, understand it’s meaning, and in order to participate in rugby, voluntarily waive potential future claims. In consideration for allowing the athlete to participate in rugby and seek the benefits of rugby, the athlete and the parent/guardian hereby assume all risks associated with participation in rugby, and hereby waive in advance all claims against USA Rugby and all subsidiary Unions and member clubs, including Cherry Creek Rugby Football Club, sponsoring person and organizations, coaches, officials, other players (on any team), their parents, and the persons owning or providing the space for rugby (hereinafter “releasees”), and agree to hold harmless and indemnify the releases regarding any claim premised upon any injury to the athlete (or athlete’s death), or to the parent/guardian, caused in whole or in part by any action or inaction by a release (including a releasee’s negligence), in connection with rugby, with travel to or from rugby, or with rugby – oriented social activities sponsored by a release.
SIGNED______________________________________________DATE__________________________ SIGNED______________________________________________DATE__________________________
HIGH SCHOOL BOYS $160 TRY $100 Send this form along with a check to: Cherry Creek Rugby Football Club 7625 South Yampa Street Centennial, CO 80016
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| Last Updated ( Thursday, 17 March 2011 ) |
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