Lehigh Valley U-19 Boys Rugby
Team Contact: Gerad Crosswy: lvrugbyheadcoach@gmail.com

****In addition to this form ALL Players are REQUIRED TO CIPP with Rugby PA. To Complete this registration please go to www.RUGBYPA.org and fill out player registration. You will need to create an account and follow instructions to register your player.

Email address *
Player first & last name *
Your answer
Date of birth *
MM
/
DD
/
YYYY
Player Phone number *
Your answer
Current School *
Your answer
Current Grade Level *
T-shirt size *
Parent/Guardian names *
Your answer
Parent/Guardian Phone number
Your answer
Parent/Guardian Email *
Your answer
Address *
Your answer
Insurance Provider and Policy Number *
Your answer
Known Allergy(ies) (or "none") *
Your answer
Relevant medical conditions (or "none") *
Your answer
In the event a parent/guardian cannot be reached, contact?(name and phone number)
Your answer
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