SENIOR MEN’S MEMBERSHIP APPLICATION

  PERSONAL INFORMATION:

NAME:

HOME PHONE:     CELL:

ADDRESS:

CITY / STATE / ZIP: 

DATE OF BIRTH:

E-MAIL ADDRESS:

EMERGENCY INFORMATION:  (EMERGENCY CONTACT)

NAME:

HOME PHONE:   CELL:

CLUB DUES ARE:  $75.00  PER SEASON OR $125 FOR BOTH THE FALL AND SPRING. 

 MONEYS COLLECTED WILL BE USED TO PAY THE FOLLOWING: TEAM & PLAYER CIPP FEES, EPRU TEAM DUES, REFEREE FEES, JERSEYS AND ALL OTHER REQUIRED TEAM EQUIPMENT. 

HIBERNIAN RUGBY FOOTBALL CLUB MEDICAL WAIVER

ARE THERE ANY MEDICAL PROBLEMS WE SHOULD BE AWARE OF?

IF YES SPECIFY:

DO YOU HAVE COMPREHENSIVE MEDICAL INSURANCE?

PLEASE PROVIDE THE NAME OF YOUR INSURANCE CARRIER:

RELEASE OF ALL CLAIMS:

WHEREAS YOU ARE THE RELEASER OF THE NAMED ABOVE AND IT IS THE WISH OF THE SAID RELEASER, THAT HE RUGBY UNDER THE AUSPICES AND CONTROL OF THE HIBERNIAN RUGBY FOOTBALL CLUB, THE EASTERN PENNSYLVANIA RUGBY UNION, THE MID-ATLANTIC RUGBY FOOTBALL UNION AND THE USARFU ITS REPRESENTATIVES, OFFICERS, SUCCESSORS AND ASSIGNS.

 NOW THEREFORE, THE RELEASER INTENDING TO BE LEGALLY BOUND DO HEREBY COVENANT AS FOLLOWS:

1.      I DO HEREBY RELEASE AND FOREVER DISCHARGE THE HIBERNIAN RUGBY FOOTBALL CLUB, THE EASTERN PENNSYLVANIA RUGBY UNION, THE MID-ATLANTIC RUGBY FOOTBALL UNION AND THE USARFU, ITS REPRESENTATIVES, OFFICERS, SUCCESSORS AND ASSIGNS, OF AND FROM, ANY AND ALL LIABILITY, ACTIONS, CAUSES OF ACTIONS, CLAIMS, DAMAGES, COSTS AND COMPENSATION, ON ACCOUNT OF, OR IN ANY WAY GROWING OUT OF, INJURIES CLAIMED TO HAVE BEEN RECEIVED BY THE ABOVED NAMED, BY REASON OF, OR IN CONNECTION WITH HIBERNIAN RUGBY.

2.      I DO HEREBY AGREE TO INDEMNIFY AND HOLD HARMLESS THE HIBERNIAN RUGBY FOOTBALL CLUB, THE EASTERN PENNSYLVANIA RUGBY UNION, THE MID-ATLANTIC RUGBY FOOTBALL UNION AND THE USARFU, ITS REPRESENTATIVES, OFFICERS, SUCCESSORS AND ASSIGNS FROM ANY CLAIMS ENUMERATED IN PARAGRAPH NUMBERED 1 ABOVE.

3.      I LIKEWISE RELEASE FROM ALL RESPONSIBILITY, ANY PERSON TRANSPORTING THE ABOVED NAMED TO AND FROM THIS ACTIVITY.

4.      I FURTHER STATE I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND THAT I SIGN THE SAME AS MY OWN FREE ACT AND DEED.

5.   PLEASE MAKE A COPY, FOR YOUR OWN RECORDS.

6.   BY SUBMITTING THIS FORM YOU HEREBY AGREE TO ALL TERMS STATED ABOVE.

          How did you hear about the Hibernian Rugby Club? Please be specific.  

           Also place any additional questions or comments here:

If you are not paying thru Pay Pal send a check payable to Hibernian Rugby Football Club or "HRFC".

Mail to the following address:

Hibo Rugby 

c/o Justin Zadnik

254 Glouster Rd

Fairless Hills, PA 19030