RECOGNIZED MEMBERSHIP APPLICATION PAGE 1 (UTAH RUGBY UNION MEMBERSHIP APP)
CLUB DECLARATION: MEN S: [ ] DI [ ] DII [ ] DIII [ ] SEVENS [ ] SOCIAL (NON COMPETITIVE) WOMEN S: [ ] DI [ ] DII [ ] SEVENS [ ] SOCIAL (NON COMPETITIVE) COLLEGIATE: [ ] MEN S DI [ ] MEN S DII [ ] WOMEN S DI [ ] WOMEN S DII YOUTH: [ ] HIGH SCHOOL [ ] U19 [ ] AGES 8 15 YEARS TEAM NAME: TEAM OFFICIALS: TITLE NAME ADDRESS PHONE / E-MAIL PRESIDENT VICE PRESIDENT SECRETARY TREASURER COACHING STAFF: TITLE NAME ADDRESS PHONE / E-MAIL HEAD COACH MANAGER PAGE 2 (UTAH RUGBY UNION MEMBERSHIP APP)
1. 2. 3. 4. 5. DO YOU HAVE ACCESS TO MEDICAL PERSONNEL / TRAINER? If yes: (Name) (Phone) DO YOU HAVE A WILLING INDIVIDUAL TO BECOME A CERTIFIED REFERREE? If yes: (Name) (Phone) IS YOUR COACH WILLING TO BECOME LEVEL 1 CERTIFIED? If no, please explain: DO YOU HAVE A DESIGNATED PRACTICE FIELD? If yes: (Location) DOES YOUR TEAM/TEAM MEMBERS HAVE A HISTORY OF ON FIELD VIOLENCE? If yes, how will you correct the problem? YES NO 6. DATE OF YOUR NEXT ANNUAL GENERAL MANAGERS MEETING: 7. WHAT FUND RAISERS ARE YOU PLANNING ON EXECUTING? WHEN? 8. WHAT EVENTS DO YOU HAVE TO IMPROVE THE IMAGE OF RUGBY IN YOUR COMMUNITY? 9. HOW WILL YOU RECRUIT NEW MEMBERS TO SECURE YOUR CLUB S FUTURE? 10. LIST YOUR CLUB S GOALS FOR THE NEXT 3 YEARS: PAGE 3 (UTAH RUGBY UNION MEMBERSHIP APP)
ROSTER: (PLEASE MAKE PHOTO COPY IF MORE SPACE IS NEEDED) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 NAME POSITION BIRTHDATE CIPP# US CITIZEN YES NO PAGE 4 (UTAH RUGBY UNION MEMBERSHIP APP)
UTAH RUGBY UNION NONDISCRIMINATION POLICY In compliance with the nondiscrimination laws of the United States and any state in the United States, the Utah Rugby Union shall conduct all its operations and programs without regards to age, sexual orientation, national origin, race, gender, political affiliation or religion. Accordingly, by applying for membership, you affirmatively certify that you adopt the Utah Rugby Union s nondiscrimination policy in conducting all your operations and programs. WAIVER OF ELIGIBILITY AND LIABILITY The undersigned representative (accountable for entire applying organization) states: 1. To the best of my knowledge and belief, every individual in our organization is eligible or will be eligible by the beginning of the competitive season under USA Rugby Guidelines (CIPP registered) to participate in this activity. 2. To the best of my knowledge and belief, we as an organization are eligible or will be eligible by the beginning of the competitive season to participate in this activity under all USA Rugby Guidelines and Utah Rugby Union Guidelines. 3. We agree to abide by all rules and regulations imposed by the International Rugby Board, USA Rugby, Utah Rugby Union and the local hosts. 4. We are aware that we may lose the privilege to participate in the activity in the event of any violation of the above mentioned statements. 5. We are aware that rugby is a contact sport and participation may result in permanent disability, social and economic loss and even death. These risks may arise as a result of our own actions or inactions, or may arise from the actions or inactions of others, or may arise from rules applied to the activity, condition of the premises and/or equipment used. 6. WE FULLY ACCEPT ALL SUCH RISKS AND RESPONSIBILITIES FOR LOSSES, COSTS AND DAMAGES incurred as a result of our participation in the activity. 7. We release, waive, discharge and covenant not to sue USA Rugby, Pacific Coast Rugby Football Union, the Utah Rugby Union, referee associations, affiliated clubs, their respective administrators, directors, agents, coaches, referees and other employees of the organizations, other participants, sponsoring agencies, sponsors, advertisers and if applicable, owners and leases of premises to conduct all rugby activities, all of which hereinafter, referred to as releases, from demands, losses or damages on account of injury, including death or damage to property caused or alleged to be caused in whole or part by negligence of the release of otherwise. APPLICANT SIGNATURE: (Printed Name) (Title/Position) (Team Name) (Signature) / / (Date) PAGE 5 (UTAH RUGBY UNION MEMBERSHIP APP)