Emergency Information
Hey ladies - fill this form out here and you won't have to do it on paper! Yay! If you feel uncomfortable submitting your social security number and/or insurance information online, skip it... but we will need to get it from you at a meeting or at your first practice. Hope you are all looking forward to a great season!
FULL NAME *
Your answer
EMAIL ADDRESS *
(email you'll use for the FWRFC list serv.)
Your answer
PHONE NUMBER *
(cell phone, or best way to quickly contact you in case of emergency
Your answer
HOME ADDRESS *
Line 1
Your answer
HOME ADDRESS Line 2
ex. Suite, Apt, P,O. Box, etc **leave blank if not applicable
Your answer
CITY *
City
Your answer
STATE *
State
Your answer
ZIP CODE *
Zip Code
Your answer
DATE OF BIRTH *
Your answer
EMERGENCY CONTACT #1 *
Please list primary contacts's name
Your answer
EMERGENCY CONTACT #1 PHONE NUMBER *
Please list primary contact's best option phone number
Your answer
EMERGENCY CONTACT #1 RELATIONSHIP TO YOU *
Please list primary contact's relationship to you
Your answer
EMERGENCY CONTACT #2
Please list secondary contact's name
Your answer
EMERGENCY CONTACT #2 PHONE NUMBER
Please list secondary contact's best option phone number
Your answer
EMERGENCY CONTACT #2 RELATIONSHIP TO YOU
Please list secondary contact's relationship to you.
Your answer
INSURANCE COMPANY
Your answer
INSURANCE POLICY NUMBER
Your answer
ALLERGIES *
please list and be specific when possible (i.e., medications, foods)
Your answer
PRE-EXISITING CONDITIONS *
concussions (and when), surgeries, asthma, etc.
Your answer
MEDICATIONS *
Choose "Other" to list medications you are currently taking
Required
CONTACTS OR GLASSES? *
Required
RUGBY POSITIONS PLAYED
check any and all that apply
POSITIONS INTERESTED IN PLAYING
check all that apply - and in case you don't know... http://en.wikipedia.org/wiki/Rugby_union_positions
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