Participant's Contact Information
* Participant Name
Date of Birth
* Date of Birth
Please tell us what you hope to get out of this clinic
Best Email Address
* Best Phone
Emergency Contact Phone 1
* Emergency Contact Phone 1
Emergency Contact Phone 2
* Emergency Contact Phone 2
Participant's Health Insurance Provider
Health Insurance Policy #
Health Insurance Group #
List Allergies or special needs
List Injuries that have occurred in last 6-months
MY WAIVER EXPRESSLY MEANS THAT:
I hereby grant permission for myself and/or my child (“Participant”) to participate in all practice sessions, camps, and other activities involving US Collegiate Development LLC. Permission extends to any travel to and from any and all practice sessions, camps, and other activities sponsored and arranged by US Collegiate Development LLC. This permission is granted without reservation. Recognizing the risks presented by the competitive contact sport of rugby, the signature below indicates a knowing, voluntary release of any claim that might be asserted against US Collegiate Development LLC, its officers, administrative assistants, coaches, assistant coaches, managers, sponsors, chaperons, designated drivers, volunteers, and any other agents representing US Collegiate Development LLC. By waiving any right to assert a claim, I am agreeing to release, absolve, indemnify and hold harmless any and all parties previously mentioned for any and all liability arising from any injuries incurred by Participant. I, the Participant and/or the Participant’s legal parent or legal guardian, accept and assume all risks and hazards inherent in and related to the activities of US Collegiate Development LLC, including any travel and from any activities sponsored and arranged by US Collegiate Development LLC. This permission also includes my authorization for emergency medical treatment deemed appropriate and necessary by any coach, assistant coach or representative or agent thereof for participant, including transport to the nearest medical facility adequate to treat the emergency.
I give my permission to US Collegiate Development LLC to use the likeness of my child (or myself) in US Collegiate Development LLC’s marketing, fundraising, information, and training efforts and materials as determined necessary and appropriate to deliver on US Collegiate Development LLC’s mission. The files may be released to appropriate vendors or professional contacts to produce the materials for promotional, advertising, or marketing purposes. I agree and consent hereby to grant a perpetual license to US Collegiate Development LLC to utilize said video(s), picture(s), or photograph(s) in advertising or other promotional services / products, without compensation or credit. Photos and video taken by US Collegiate Development LLC of me and / or my child shall remain the property of US Collegiate Development LLC, and I agree that there is no compensation to me for having these materials published, nor do they need to be submitted to me for inspection.
Who Is Filling Out This Form?
If different than participant
Last Name, First Name
Thank you for submitting your US Collegiate Development Camp Medical Release. We look forward to working with you and / or your aspiring child.