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Document Sample
“Grizzlies”
Colorado Springs
High School Rugby Club
2012 ~ USA Rugby Membership
Affiliated Rugby Unions and Rugby Club
ENROLLMENT INFORMATION
Previously Registered with USA Rugby–CIPP #
New Participant 2012
Player Information
Resident High School:
Date of Birth(mm/dd/yyyy): Age: Gender: Male Female
First Name: Last Name:
Mailing Address:
City: State: Zip:
Home Phone: Mobile Phone:
Email Address: Facebook:
Parents / Guardian Contact Information
Mother: First Name: Last Name:
Home Phone: Work Phone: Mobile Phone:
Email Address:
Father: First Name: Last Name:
Home Phone: Work Phone: Mobile Phone:
Email Address:
I hereby affirm that the above information is true and correct, and that I have read and agree to the terms of
the waiver below in this form. (Under 18 yrs then Parent / Guardian Sign)
Player’s Signature: Date:
If under 18 years of age then a parent / guardian must sign below
Parent / Guardian Signature: Date:
Total Annual Player Membership Fee $300
Incorporates
USA Rugby, Colorado Youth Rugby, Eastern Rockies Rugby Union, Colorado Springs High School Rugby Club
METHOD OF PAYMENT: Cash or Personal Check payable to: CSHSRC
Code of Conduct
As a registered member / player for the Colorado Springs High School Rugby & affiliated rugby unions, I
hereby agree to behave myself in an orderly & responsible manner throughout the 2011 rugby season.
Participation for the Colorado Springs High School Rugby Team is a privilege. The opportunity to present
oneself to the public and to represent one's family, school, city and state should not be taken lightly.
1. Be a credit to yourself, your parents, your school your club and your community.
2. Maintain good academic standing according to the CHSAA by-laws. D’s and F’s will result in
possible loss of playing time.
3. Display high standards of social behavior at all times.
4. Demonstrate respect for and acceptance of the rules of competition.
5. Demonstrate respect for those in authority, including coaches, referees, and side line officials and
supporting parents.
6. Display a strong spirit of cooperation, and loyalty.
7. Use language that is socially acceptable towards officials, spectators, opponents, coaches and the
general public.
8. Participate in at least 90% of the practice sessions, games and meetings.
9. The use or possession of tobacco, drugs, steroids or alcoholic beverages will not be tolerated. Any
violation will result in suspension from club activities.
10. Abide by the rules of play as set forth and explained in the text of USARFU handbook and laws of
the game for the 2010 season. (www.usarugby.org)
11. This contract is in effect as of the signing date and until the culmination of the current season to
include playoffs and championship matches.
Non-conformers to this Code of Conduct policy will be subjected to enhanced physical fitness
conditioning, suspension from any number of matches and or expulsion from the team for the remainder of
the season.
As parent of _________________________, I and my son / daughter have read the above rules and understand
that my son /daughter will be governed by these rules as a player for the Colorado Springs High School
Rugby Club, Colorado Youth Rugby, the Eastern Rockies Rugby Football Union, and USA Rugby.
____________________________ __________________________________ ____________________
Signature Parent / Guardian Printed Name Date
____________________________ _________________________________ _____________________
Signature Player Printed Name Date
For further information on 2012 fees please contact
John Paterson (719) 201 3338 ~ john@coloradospringsrugby.com
Otis McGregor (719) 640-7766 ~ Otismcgregor3@gmail.com
Page 2
MEDICAL INSURANCE AGREEMENT AND USA RUGBY RULES ACKNOWLEDGEMENT
1. I acknowledge that I have a medical insurance policy in my name that has a minimum of $100,000 in
medical coverage WITH NO RESTRICTION FOR ACCIDENTS WHILE PARTICIPATING IN
SPORTS. I understand such insurance will be my primary source of payment should medical
treatment be necessary as a result of my participation in the Activity.
2. I agree to abide by all International Rugby Board, USA Rugby, territorial and local area union rules and
regulations, including to be bound by the arbitration procedures therein, that I am aware of and
understand, for any dispute regarding my right to participate in the Activity, as set forth in the Bylaws
of USA Rugby, as they are amended on a periodic basis, which I understand are available on the USA
Rugby web site (www.usarugby.org).
3. I affirm that I am not suspended or banned from play or participation by any club local area union,
territorial union, or national union, and I authorize USA Rugby to verify my citizenship status with the
appropriate governmental agencies
4. I am aware that USA Rugby has the right to revoke my CIPP enrollment, and therefore my eligibility to
play or coach, in the event of any violation of the aforementioned statement.
WAIVER & RELEASE, ASSUMPTION OF RISK AND PARENTAL INDEMNIFICATION
In consideration of me being permitted to participate in any way in USA Rugby, its member unions, clubs,
organizations and individuals sponsored Activities (“Activity”), I agree:
1. I understand the nature/dangers of USA Rugby activities and believe that I am qualified to participate
in such Activity. I further acknowledge that I am aware the activity will be conducted in facilities open
to the public during the Activity. I further agree/warrant that if at any time I believe conditions to be
unsafe, I will immediately cease further participation in the Activity.
2. I FULLY UNDERSTAND that: (a) USA RUGBY Activities involve risks and dangers of SERIOUS
BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS AND DEATH (“Risks”);
(b) these Risks and dangers may be caused by my own actions, or inaction’s, the actions or inaction’s of
others participating in the Activity, the condition in which the Activity takes place. Or THE
NEGLIGENCE OF THE “RELEASEES” NAMED BELOW; (c) there may be other risks and social and
economic losses either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND
DAMAGES incurred as a result of my Participation in the Activity.
3. I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY
AND SAVE AND HOLD HARMLESS USA RUGBY, their member unions, territorial unions, clubs,
respective administrators, directors, agents, officers, volunteers, and employees, other participants, any
sponsors, advertisers, and if applicable, owners and lessors of premises on which the Activity takes
place (each considered one of the “Releasees” herein) from all liability, claims demands, losses, or
damages on my account caused or alleged to be caused in whole or in part by the negligence of the
“Releasees” or otherwise, including negligent rescue operations and further agree that if, despite this
release, I or anyone on my behalf makes a claim against any of the Releasees named above, I WILL
INDEMNIFY, SAVE AND HOLD HARMLESS EACH OF THE RELEASEES FROM ANY
LITIGATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY, DAMAGE OR COSTS ANY MAY
INCUR AS THE RESULT OF ANY SUCH CLAIM.
For further information on 2012 fees please contact
John Paterson (719) 201 3338 ~ john@coloradospringsrugby.com
Otis McGregor (719) 640-7766 ~ Otismcgregor3@gmail.com
Page 3
I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND IT’S TERMS, UNDERSTAND THAT I HAVE
GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT ANY
INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND
UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND
AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THAT THE BALANCE,
NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
____________________________ _________________________________ _____________________
Signature Player Printed Name Date
For further information on 2012 fees please contact
John Paterson (719) 201 3338 ~ john@coloradospringsrugby.com
Otis McGregor (719) 640-7766 ~ Otismcgregor3@gmail.com
Page 4
PARENTAL CONSENT AND INDEMNIFICATION AGREEMENT
I, the minor’s parent and/or legal guardian, understand the nature of the above referenced activities and the
minor’s experience and capabilities and believe the minor to be qualified to participate in such “activity”. I
hereby release, discharge, covenant not to sue and AGREE TO INDEMNIFY AND SAVE AND HOLD
HARMLESS each of the Releasees from all liability, claims, demands, losses, or damages on the minor’s
account caused or alleged to have been caused in whole or in part by the negligence of the Releasees or
otherwise, including negligent rescue operations, and further agree that if, despite this release, I, the minor, or
anyone on the minor’s behalf makes a claim against any of the above Releasees, I WILL INDEMNIFY, SAVE
AND HOLD HARMLESS each of the Releasees from any litigation expenses, attorney fees, loss liability,
damage or cost any Releasees may incur as the result of any such claim.
_______________________ __________________________________ ________________________
Signature Parent / Guardian Printed Name Date
For further information on 2012 fees please contact
John Paterson (719) 201 3338 ~ john@coloradospringsrugby.com
Otis McGregor (719) 640-7766 ~ Otismcgregor3@gmail.com
Page 5
Colorado Springs High School Rugby Club
EMERGENCY CONTACT/AUTHORIZATION TO CONSENT TO MEDICAL
TREATMENT FOR A MINOR
Player’s Name: Age: Sex:
Address:
City: State: Zip:
Home Phone: Mobile Phone:
School: Grade:
List two persons to contact in case of Emergency:
Parent/Guardian:
Address:
City: State: Zip:
Home Phone: Work Phone: Mobile Phone:
Second Contact:
Address:
City: State: Zip:
Home Phone: Work Phone: Mobile Phone:
Important Information:
INSURANCE COMPANY: POLICY No.:
PHYSICIAN’S NAME: PHYSICIAN’S PHONE:
ARE YOU ALLERGIC TO ANY DRUGS? IF SO, WHAT?
ALLERGIES, IF ANY? (i.e., bee sting, dust)
DO YOU SUFFER FROM ASTHMA? DIABETES? EPILEPSY?
ARE YOU ON MEDICATION? IF SO WHAT?
HAVE YOU HAD ANY CONCUSSIONS? IF SO WHEN?
IF SO, PLEASE LIST
PREVIOUS INJURIES? INJURIES AND WHEN?
For further information on 2012 fees please contact
John Paterson (719) 201 3338 ~ john@coloradospringsrugby.com
Otis McGregor (719) 640-7766 ~ Otismcgregor3@gmail.com
Page 6
I, __________________________________(parent or guardian) of the city of Colorado Springs in the county of
El Paso, Colorado, do hereby state that I am the natural parent or legal guardian having custody of
______________________ ________a minor, age _______born (month/day/year) ___________________
In connection with my son / daughter participation in rugby, I authorize any accompanying adult bringing
my son / daughter 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 services in connection with the
decisions for such immediate care.
________________________________ __________________________________ ________________________
Signature Parent / Guardian Printed Name Date
________________________________ __________________________________ ________________________
Signature Player Printed Name Date
For further information on 2012 fees please contact
John Paterson (719) 201 3338 ~ john@coloradospringsrugby.com
Otis McGregor (719) 640-7766 ~ Otismcgregor3@gmail.com
Page 7
