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Complete this form to register for one of our Empire Youth Sports Spring Sessions! 

FORT TILDEN RUGBY at Fort Tilden Rugby Field
MONDAYS
3:30pm-4:30pm
April 15 - June 17
*Excluding 5/27*
$280

BAY RIDGE RUGBY at Tom Joyce Field (OLPH Soccer Field)
WEDNESDAYS
April 10 - June 5
3:30-4:30pm
Grades PreK - 6th Grade
$280

Please bring your own ball to all sessions!

If you have any questions or issues with this form email us at upandunderkidsrugby@gmail.com
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Child First Name: *
Child Last Name: *
Parent Name *
Child Grade: *
Child Date of Birth *
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Child Age: *
Child's School: *
Parent/Guardian Email 1: *
Parent/Guardian Email 2:
Parent/Guardian Emergency Cell Phone Contact 1: *
Parent/Guardian Emergency Cell Phone Contact 2:
Payment Method: *
E-WAIVER 1: PHOTO, PRESS, AUDIO, & ELECTRONIC MEDIA RELEASE FOR MINORS

I hereby grant permission to R is for Rugby LLC (DBA Empire Youth Sports) to use, including to display publicly, the above-named minor’s image, likeness, or voice recording on the class web site or in any other official class publications without further notice or compensation. I hereby consent that any such image, likeness, or voice contained in photographs, recordings, and tapes are the property of R is for Rugby LLC, which shall have the right to print, reprint, publish, copy, vend, perform or represent publicly, or create derivative works based on and using the image, likeness, or voice depicted in such photograph, film, or sound recording as it may desire free and clear of any claim whatsoever on my part or the part of the above-named minor.

I also understand that once the above-named minor’s image, likeness, or voice recording is published on a web site, it can be downloaded by any computer user. Personal information, such as a minor’s full name, parent/guardian’s names, addresses and telephone number will never be published. If a minor’s name is used with a photograph, film, or sound recording, it will be in the form of a first name and last initial. For example, student Jane Doe may be listed as “Jane D.”

Therefore I agree to indemnify, defend and hold harmless R is for Rugby LLC (DBA Empire Youth Sports), its officers, employees, agents, successors and assignees (the “Indemnified Parties”) from and against any and all claims and liabilities resulting from this publishing.
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Required
E-WAIVER 2: PARTICIPATION AGREEMENT

The Undersigned understand that  sports are physical with the possibility of injury. With that knowledge, the Undersigned hereby accept the risks that accompany participation in sports and confirm that the participating child is cleared for physical activity and exercise. The Undersigned agree that they will not hold the R is for Rugby LLC, Up & Under Rugby, Empire Youth Sports, Michael Petri, NYC Parks Department, Fort Tilden Gateway National Recreation Area, OLPH, or any coaches, administrators, officials, staff, representatives, employees, insurers, or re-insurers liable for any and all claims including, but not limited to, injury, sickness, disability, paralysis, or death; that may result from participation in the sport of rugby or from participation in Empire Summer Camp.

RELEASE AND WAIVER OF LIABILITY: IN CONSIDERATION OF THE PLAYER’S RIGHT TO PARTICIPATE, THE UNDERSIGNED HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE R is for Rugby LLC, Up & Under Rugby, Empire Youth Sports, Michael Petri, NYC Parks Department, Fort Tilden Gateway National Recreation Area, OLPH, or any coaches, administrators, officials, staff, representatives, employees, insurers, or re-insurers for any and all claims including, but not limited to, injury, sickness, disability, paralysis, or death; that may result from participation in the sport of rugby or from participation in Empire Summer Camp.

THE UNDERSIGNED AGREE THAT THIS RELEASE IS BINDING AND EFFECTIVE AS TO THEMSELVES AS WELL AS TO THEIR PERSONAL REPRESENTATIVES, ESTATES, ASSIGNS, HEIRS, AND NEXT OF KIN AND THAT IT APPLIES TO ANY AND ALL LOSS OR DAMAGE INCLUDING, BUT NOT LIMITED TO, INJURY, DISABILITY OR DEATH. I give permission for the coaches and/or organizers of Up & Under Rugby to act as a guardian to my child in the case that my child is in need of medical assistance and I can not be reached. The Undersigned understand that by signing this release they are giving up substantial rights they would otherwise have to recover damages for losses and they agree that they are doing so voluntarily and without inducement, threat, or duress. The Undersigned agree that they had the opportunity to seek legal advice before signing this release and have either done so, or have voluntarily elected not to and waive this opportunity.

I am aware that by traveling to Empire Youth Sports and participating in sports and related activities with Empire Youth Sports (R is for Rugby LLC), I am at risk at spreading or contracting COVID-19 (coronavirus) and waive all claims against Empire Youth Sports (R is for Rugby LLC) for potential exposure, transmission and complications that may result from such exposure and still choose to have my child participate in rugby and related activities with Empire Sports Camp (R is for Rugby LLC). I further certify that I am not currently infected with COVID-19 (cornonavirus), do not currently have a fever or symptoms of COVID-19 (coronavirus) and have not been exposed or potentially exposed within the past two weeks.

THE UNDERSIGNED AGREE THAT THIS RELEASE IS BINDING AND EFFECTIVE AS TO THEMSELVES AS WELL AS TO THEIR PERSONAL REPRESENTATIVES, ESTATES, ASSIGNS, HEIRS, AND NEXT OF KIN AND THAT IT APPLIES TO ANY AND ALL LOSS OR DAMAGE INCLUDING, BUT NOT LIMITED TO, INJURY, DISABILITY OR DEATH. I give permission for the coaches and/or organizers of Empire Youth Sports (R is for Rugby LLC) to act as a guardian to my child in the case that my child is in need of medical assistance and I can not be reached. The Undersigned understand that by signing this release they are giving up substantial rights they would otherwise have to recover damages for losses and they agree that they are doing so voluntarily and without inducement, threat, or duress. The Undersigned agree that they had the opportunity to seek legal advice before signing this release and have either done so, or have voluntarily elected not to and waive this opportunity.
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Required
E-WAIVER 3: CONSENT TO TREAT & RELEASE

I hereby give permission to the coaches, trainers, and/or staff members of Empire Youth Sports to take whatever action is necessary for the health and welfare of my child including consenting on my behalf to any and all medical treatments, procedures, operations, and/or hospitalizations. I further agree to hold them harmless and indemnify them for all medical bills incurred for the treatment of my child. I understand that rugby is a sport that can result in serious injury. I hold R is for Rugby LLC and Empire Youth Sports, its coaches, trainers, and staff members harmless and hereby release them from liability for any injury to my child while attending the classes. *Parents will be contacted in the event of any injury to their child while attending class.
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Required
I have read, understand, and AGREE to the terms outlined in the above waivers:

PARTICIPATION AGREEMENT
PHOTO, PRESS, AUDIO, AND ELECTRONIC MEDIA RELEASE FOR MINORS
CONSENT TO TREAT AND RELEASE

By typing your name in the space provided, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.
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