Silicon Valley Rugby Football Club–2009-2010 Season Application

USA Rugby Club ID: 20544 Website: http://www.siliconvalleyrugby.org
Please complete the form below with the appropriate signatures and return it with your $110 Season Dues (scholarships available based on need).

Starting this season you must pay USA CIPP and Pacific Coast Fees directly at https://membership.usarugby.org

CIPP Number:

First Name	Last Name
Street	Birth Date	Citizenship
City	State	Zip
My Phone (cell/home)	Other Phone (cell/home)
e-Mail	Waist Size	Height Weight
School	Grade
Father Full Name	Father Phone
Mother Full Name	Mother Phone
Father e-Mail	Mother e-Mail
Emergency Contact	Emergency Phone
Insurance Carrier	Medical Number
Medical Concerns	(Asthma) (Allergies)

I/we have read and agree to the terms of the USA Rugby Liability Waiver incorporated by reference (or on back of this form). I understand and agree that signing below is the same as signing the USA Rugby Liability Waiver separately.
I agree to support my teammates by attending all practices and games between December and May (or notifying the coach in advance of any inability to attend). I agree to keep myself fit and to play is a safe manner. I understand that my failure to follow the teams training rules affects the whole team and will result in discipline, possibly including suspension from the team.

Player Signature _______________________________________________ Date _______________

In addition to the terms of the Liability Waiver, I agree to support my son and the team by making sure dues are paid, by providing required safety equipment (mouth guard and Rugby cleats), by maintaining medical coverage for my son.
I also agree to complete the Positive Coaching Alliance Parent Pledge.
Also, I can help with: game day transportation    home game BBQ's    parent coordination    field setup    tours   

Parent Signature _______________________________________________ Date _______________