Rugby registration if you want to complete by Tues

Pius Xi Girls Rugby
2009-2010 Registration Form

Name: ______________________________________________________

Address: ____________________________________________________

City/zip: ____________________________________________________

Date of Birth: _______________________________________________

Parent’s names:_______________________________________________

Player email: _________________________________________________

Parent’s email:________________________________________________

Home phone: _________________________________________________

Player cell: __________________________________________________

Parent cell: __________________________________________________

TAC: ______________________________________________________


Consent to medical treatment for a minor

In connections with ______________________________ ‘s (players full name) participation in the Pius XI Girls Rugby team, I give consent for any accompanying adult team representative bringing my daughter for emergency medical treatment the right to consent for medical treatment as advised by a physician when the need is immediate and/or when efforts to contact me are unsuccessful. This consent if valid from today’s date until the end of the 2009-2010 school year. I also hereby stat that I have legal custody over the minor athlete listed below and that the athlete has medical insurance coverage of at least $100,000.


Athlete’s Name:______________________________________________

Parent/Guardian’s Name: _______________________________________________________(print)

Parent/Guardian’s signature: ________________________________________________________

Date: ___________________________________________________

Emergency Medical Information

Emergency contact person & phone numbers
1)
2)
3)

Insurance Provider: Group #
Primary:

Secondary:

Family Doctor Name & number


Medications currently taken:


Known allergies:


Previous injuries or medical conditions relevant to athletic participation:






Please provide copy of insurance cards