EmailMe Form - 2018 Eastern Ontario Rugby Union

Athlete Name *

First Last

Please put full first and last name as registered with rugby programs

Name you go by if not above

First Last

Born in year *

Birth Date *

MM / DD / YYYY

Athletes Main Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Athlete's Phone

### - ### - ####

Athlete Email *

Parent/Guardian 1 (first contact) *

First Last

Parent/Guardian 1 Phone *

### - ### - ####

Parent/Guardian 1 Email *

Parent/Guardian 2 (first contact)

First Last

Parent/Guardian 2 Phone

### - ### - ####

Parent/Guardian 2 Email

Did You Play High School Rugby

Yes

No

High School Team Name

Position (s) played High School

Did You Play Club Rugby

Yes

No

Club Name and Level (u15/16 etc)

Position (s) played club

Medical Conditions

please list any medical conditions we should be aware of that is currently effecting your play/training - diabetes, asthma, concussion, allergies, muscle injury, mental health - this disclosure is on your behalf and kept with confidence - if you wish to speak with a staff member instead, please say so here.

OHIP number

Emergency Contact *

First Last

This person is someone who can be contacted in the case of parent/guardian is not reachable - as such they should have information as to any medical personal issues

Emergency Contact Phone *

### - ### - ####

Relationship to You *

Are you currently registered to play rugby with an EORU club. *

yes

no

unsure

please attach receipt for club fees as proof

Profile Picture

Please attach a head shot for the coaches to have attached to your file - it should be a small head shot - no bigger than half a cell phone

Waist Measurement for Shorts in Inches *

Training Shirt size - Women's sizes (aprox) *