Season Commitment - Rebellion Rugby

DO NOT SUBMIT THIS FORM UNTIL:

• You have completed registration at USA Rugby

• If you require a 50% waiver as a full time student, are unemployed, and/or experiencing financial hardship, you must contact the Rebellion Club President

Name

First

Last

Pronouns

Emergency Birth Allergens

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone

USA Rugby ID #

7 digits

Date of Birth

Shirt Size

I have reviewed the Rebellion Policies document *

I have reviewed the Rebellion Policies document

Clear Signature

Signature

Health Insurance

Carrier

Member ID

Allergens

No Known Allergens

No Known Allergens

Emergency Contact

Name

First

Last

Relationship

Phone #

Payment

Pay in Full
Pay in 3 Installments
Full Waiver

* Financial waivers require pre-approval from the President

Membership • Pay in Full

First Year • Rookie - $240.00
First Year • Rookie with waiver* - $120.00
Returning Member - $300.00
Returning Member with waiver* - $150.00

Membership • Pay in 3 Installments

First Year • Rookie - $80 x3
First Year • Rookie with waiver* - $40 x3
Returning Member - $100 x3
Returning Member with waiver* - $50 x3

Billing