Clinic Registration - Player

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Gender *

Male

Female

Date of Birth *

Age *

School Name *

Grade In School *

Rugby Club you play for *

Position(s) you play *

Standard Fees are $30. Special New Year's Day price is $25. Late sign up after 1/10/2019 goes up to $40.

Registration Fees *

Player Fees on 1/1/2019 $25.00

Player Fees $30.00

Players Fees after 1/10/2019 $40.00

Contact Information

Home Phone *

Family Email Address *

Alternate Email Address *

Contact Name *

Contact Phone *

Medical Information

Medical Information Please indicate if your child has any medical conditions or emergency medications
of which we should be aware. (E.G. Allergies/Asthma) If necessary, include additional written instructions.

Scholarships

A limited number of partial and full scholarships are available. A partial scholarship recipient pays $10
and the fee is waived for a full scholarship. If you have need, please briefly explain your situation
and we will confirm via e-mail or phone. Choose pay by check if you want to apply for scholarship and wait for our reply.

RELEASE, INDEMNIFICATION AND HOLD HARMLESS AGREEMENT

NEW Rugby Foundation requires that all participants sign and bring the NE Wisconsin waiver to check in.

I acknowledge that I must read, sign and turn in at check in the NEW waiver to participate in the clinic. *

Yes

Clinic Registration - Player

Contact Information

Medical Information

Scholarships

RELEASE, INDEMNIFICATION AND HOLD HARMLESS AGREEMENT

SPONSORS