Norrisville Recreation Council - (White Hall, MD)

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Mason Dixon Youth Rugby Registration Form 2024

PLAYER INFORMATION

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

* Phone:

* Birthdate:

* Email:

* Gender:

* Shirt Size:

PARENT/GUARDIAN #1

* First Name:

* Last Name:

* Email:

* Primary Phone:

PARENT/GUARDIAN #2

First Name:

Last Name:

Email:

Primary Phone:

EMERGENCY CONTACT INFORMATION

*Emergency Contact will be used in the event that Parent/Guardian cannot be reached.

* First and Last Name:

* Phone:

* Relationship to Player:

MEDIA CONSENT AND RELEASE FOR MINOR CHILDREN

I hereby grant Mason Dixon Rugby the absolute right and permission to use photographic portraits, pictures, digital images, or videos of My Child, or in which My Child may be included in whole or part, or reproductions thereof in color or otherwise for any lawful purpose whatsoever, including but not limited to use in any club websites, social media pages, and other publications. I do this with full knowledge and consent and waive all claims for payment or any other consideration.

* Media Consent:

Are there physical conditions or allergies of which the coach/administrator should be aware?:

WAIVER INFORMATION

I certify that the individual named above is in good physical condition and is capable of participating in the named program. If medical attention beyond first-aid treatment is required, I understand that every attempt will be made to contact me at the emergency number provided. If contact with me is not possible, I give permission for medical attention to be administered. Furtermore, I hereby release, exonerate and discharge the organizers, officers, volunteers, coaches, officials, representative, employees, and agents from any and all actions and for any injuries or damages incurred while participating in, or traveling to and from, this program.

In accordance to Maryland law, I hereby acknowledge that I have received the information regarding concussions published by the United States Department of Health and Human Services Centers for Disease Control and Prevention (CDC). For additional information I understand that I may call 1-800-232-4636 or go to www.cdc.gov/concussion/HeadsUp/youth.html.

I/we agree with the above *

* indicates required fields