ELYSIAN CHARTER SCHOOL RUGBY
FALL 2018 REGISTRATION FORM
Student Name ____________________________
Age ________ D.O.B. ___________ Grade/Teacher _________
Parent/Guardian #1: __________________________ Cell# ____________________
E-mail address: _______________________________
Parent/Guardian #2: __________________________ Cell# ____________________
E-mail address: _______________________________
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After practice, my child has permission to:
___ Self-Dismiss ___ Picked-Up by: ____________________________
___ After-Care
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Does your son/daughter have any medical problems or allergies that we should know about?
________________________________________________________________________________________________________________________________________________
If yes, please describe the type of medication, dosage, frequency, and administration; as well as authorized to administer. ______________________ _______________________________________________________________________
I GIVE PERMISSION FOR MY CHILD ________________ TO PARTICIPATE IN ELYSIAN CHARTER SCHOOL’S RUGBY PROGRAM. HE/SHE IS PHYSICALLY CAPABLE OF PERFORMING IN THIS SPORT. ALSO, MY CHILD’S MEDICAL PAPERWORK IS UP TO DATE WITH THE SCHOOL.
____________________________________________ _________________
SIGNATURE OF PARENT/GUARDIAN DATE
