Rugby Camp Powered by Atavus
Event Timing: April 29, 2017
Event Address: 4064 Vilas Road Cottage Grove, WI
Contact us at (920) 342-7675 or
First and Last Name of Participant
Participant Date of Birth
Required because law (COPPA) prevents storing information for kids under 13 years old without parental consent.
Emergency Contact Name
Emergency Contact Phone Number
Which school/club team do you play for?
How long have you been playing rugby?
How did you hear about this camp?
Anything we should know about? E.g. asthma or EpiPen?
Waivers and Agreements
Please read the following waivers and agreements carefully. They include release of liability and waiver of legal rights, and deprive you of the ability to sue certain parties. By agreeing electronically, you acknowledge that you have both read and understood all text presented to you as part of the registration process.
A concussion is a brain injury, and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussions are mild, all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. You can’t see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If the player reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away. Symptoms may include one or more of the following: headaches, amnesia, pressure in head, not feeling "right", nausea or vomiting, fatigue or low energy, neck pain, sadness, balance problems or dizziness, nervousness or anxiety, blurred/double/fuzzy vision, irritability, sensitivity to light or noise, more emotional, feeling sluggish or slowed down, confusion, drowsiness, change in sleep patterns, repeating the same question/comment, feeling foggy or groggy, and concentration or memory problems (forgetting game plays). Signs observed by teammates, parents and coaches include: appears dazed, vacant facial expression, confused about assignment, forgets plays, unsure of game/score/opponent, answers questions slowly, moves clumsily or displays poor coordination, slurred speech, shows behavior or personality changes, seizures or convulsions, can’t recall events prior to hit, can’t recall events after hit, any change in typical behavior or personality, and loses consciousness. Athletes with the signs and symptoms of concussion should be removed from play immediately. Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is well known that adolescent or teenage athlete will often under report symptoms of injuries, and concussions are no different. As a result, education of administrators, coaches, parents and students is the key for student-athlete’s safety. Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately. No athlete may return to activity after an apparent head injury or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. Close observation of the athlete should continue for several hours.
I hereby grant permission for myself and/or my child (“Participant”) to participate in all practice sessions, camps, and other activities involving ATAVUS and MADISON UNITED RUGBY ("MUR"). This permission is granted without reservation. Recognizing the risks presented by the competitive contact sport of ATAVUS and MUR, the signature below indicates a knowing, voluntary release of any claim that might be asserted against ATAVUS or MUR, its officers, administrative assistants, coaches, assistant coaches, managers, sponsors, chaperones, volunteers, and any other agents representing ATAVUS or MUR. 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 (including, but not limited to, bruises, sprains, broken bones, head and neck injuries, paralysis, and death) incurred by Participant, including such claims which allege negligent acts or omissions of ATAVUS or MUR. My waiver expressly means that 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 ATAVUS and MUR. 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. Should ATAVUS or MUR, or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portion shall remain in full force and effect.
By entering my name below, I assert that I have reviewed, understood, and agree to all the waivers I selected above. I agree that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against ATAVUS or MUR on the basis of any claim from which I have released them herein.
and pay in the new window.
Or mail a $140 check payable to Madison United Rugby at PO Box 45598 Madison, WI 53744.
Your spot is not guaranteed until payment is received. You will receive confirmation via email.
Be sure to click Submit at the bottom of this form.
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