2021 Midstate Rugby - Youth Tackle Clinic - Fall
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Player first name *
Player last name *
Gender *
Date of birth *
MM
/
DD
/
YYYY
Grade level *
Note: Grades are for current 2021-2022 school year
Street Address *
City *
State *
Zip Code *
What school do you attend? *
Code of Conduct-Player *
Required
Parent 1 Contact Name *
First Last
Parent 1 Phone Number *
(###) ### ####
Parent 1 Email *
Parent 2 Contact Name (optional)
First Last
Parent 2 Phone Number (optional)
(###) ### ####
Parent 2 Email (optional)
Code of Conduct-Parent(s) *
Required
Injury Treatment Waiver *
Required
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