contact us

Use the form on the right to contact us.

You can edit the text in this area, and change where the contact form on the right submits to, by entering edit mode using the modes on the bottom right.

Use the form on the right to contact us.

You can edit the text in this area, and change where the contact form on the right submits to, by entering edit mode using the modes on the bottom right.

 
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 ©2013 US Collegiate Development LLC. The shield logo and Jakl logo are trademarks of US Collegiate Development LLC.

9 Reservoir Road
Hanover, NH 03755
USA

(321) 480-3429

Clinic Participation Form

Please fill out the below form for each clinic participant. Parent/Guardian will need to agree and sign if under 18. To fill out the form for a 2nd participant and beyond, please fill out the form completely for the 1st participant, agree, and then reload the page. 


 
Participant's Contact Information
Participant Name *
Participant Name
Date of Birth *
Date of Birth
Please tell us what you hope to get out of this clinic
Best Phone *
Best Phone
Address *
Address
Participant Type *
Please check all that apply
Registered with USA Rugby? *
Participants should be registered with the national governing body, USA Rugby
Team Level *
Please check all that apply
How did you hear about US Collegiate Development?
Please check all that apply
Medical Information
Last Name, First Name
Emergency Contact Phone 1 *
Emergency Contact Phone 1
Emergency Contact Phone 2 *
Emergency Contact Phone 2
Medications (Including Inhalors) *
WAIVER:
(check each box)
MY WAIVER EXPRESSLY MEANS THAT: *
ACKNOWLEDGEMENT: *
MEDIA RELEASE: *
I agree to this electronic signature. Type "/" then full legal name, then "/" again:
Date *
Date
Who Is Filling Out This Form?
If different than participant