New Player Signup/USA Rugby Medical History

The following information is required for you to participate in practices and games with the Charlotte Royals. It allows us to provide you with the proper equipment, be aware of contacts in case of emergency, and ensure that we are informed of any medical concerns that you would like to make known. 

Contact Info
Name *
Name
Address *
Address
Phone *
Phone
Do you have primary health insurance? *
Emergency Contact Info
Contact Name *
Contact Name
Emergency Contact Phone *
Emergency Contact Phone
Rugby Experience
Health Statement
The following information is voluntary. We will use this information only if you get injured during any activity associated with the Charlotte Royals Rugby Football Club. The Charlotte Royals is not liable for any injury you might sustain while participating in Charlotte Royals Rugby Football Club activities nor any pre-existing condition you might have that may affect you during rugby activities. You should always consult a physician before playing this or any other sport. *
Waiver Clause *
In consideration of the acceptance of this application for membership and being permitted to play with Charlotte Royals RFC (Charlotte Royals), I hereby release and discharge Charlotte Royals, its players, executive members, coaches, and managers (members) from any and all liabilities, actions causes of actions, claims and demands for damages, interest, costs, loss or personal injuries, however arising and including, but not limited to: injuries from the negligence of the Charlotte Royals or its members which may have been or may hereafter be sustained by me in consequence of participating in or watching the rugby games, practices and social activities (rugby activities) organized by the Charlotte Royals. I hereby acknowledge that no warranties or conditions have been made, either expressed or implied, that rugby activities organized by Charlotte Royals shall be conducted as to prevent or minimize the risk of personal injury, and furthermore I acknowledge that Charlotte Royals makes no representation whatsoever as to the ability of its players or members to participate in rugby activities in a safe manner. I further agree to save harmless and indemnify the Charlotte Royals, its players, executive members, coaches and managers from and against all claims for damages, interest and/or costs which may be made by a claimant related to me, as a result of participating in or watching the rugby activities. I further acknowledge that I am aware of all the risks in the performance of such rugby activities, including, without limitation, the risk of sustaining injury or harm as a result of being struck by a player, ball, cleats or other piece of equipment; or as a result of a fall or collision resulting from the carelessness or clumsiness of one or more people or as a result of and defect in the rugby field. I further acknowledge that I have voluntarily assumed these risks.
USA Rugby Medical Questionnaire
Date of Birth *
Date of Birth
The above questions have been answered completely and truthfully to the best of my knowledge. *