Participant Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Participant's goals
*
Please tell us what you hope to get out of this camp
Best Email Address
*
Best Phone
*
Country
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Participant Type
*
Please check all that apply
Registered with USA Rugby?
*
US participants should be registered with the national governing body, USA Rugby
School
Team
*
Shirt Size
*
Small
Medium
Large
X-Large
XX-Large
How did you hear about US Collegiate Development?
Please check all that apply
Emergency Contact Phone 1
*
Country
(###)
###
####
Emergency Contact Phone 2
*
Country
(###)
###
####
Doctor's Phone
*
Country
(###)
###
####
Participant's Health Insurance Provider
Health Insurance Policy #
Health Insurance Group #
Medications (Including Inhalors)
*
List Medications
List Allergies or special needs
List Injuries that have occurred in last 6-months
MY WAIVER EXPRESSLY MEANS THAT:
*
ACKNOWLEDGEMENT:
*
MEDIA RELEASE:
*
Date
*
MM
DD
YYYY
Last Name, First Name
