Registration Form: MatiesRugbyAcademy: Schools

Player information
Name and Surname
Date of Birth
Age on 1 January 2013
Grade
Gender
School
Language
Number of sport activities
Number of hours sport per week
Contact details of parent
Name and Surname
Home address
Cell phone
E-mail address
Phone number (home)
Phone number (work)
Fax number
Medical history
(Answer Yes/No and give an explanation)
Injuries
Concussion
Medical conditions
Allergies
Asthma
Diabetes
Operation(s)
Blood pressure problems
Current medication
Other
Medical aid
Principal Member
Name of fund
Member number
ID number Principal Member
Relationship

Payment Information

  1. Payment must be made into the following bank account. NO CHEQUE payments will be accepted.

Bank:Standard Bank

Account name:University of Stellenbosch

Account number:073006955

Branch code:05061045

Reference:SSRK7 AND YOUR CHILD’S NAME AND SURNAME

Type of account:Cheque

Please fax proof of payment to 021-8083919. Clearly mark the fax for attention: Maties Schools

  1. If you would like to cancel a session, for whatever reason, cancellation must be done 2 days prior to the next session otherwise a cancellation fee of R50 will be levied against you.
  2. Payment must be made on/before the last working day of every month. In the event of payment not received in time, your child’s place cannot be guaranteed for the following month.

Contact Information

021808 9033

Undertaking of parent/guardian of minor child

1.______(name of child) will join for _____ months (guaranteed 4 sessions per month) at R240 per month and a registration fee of R220.(Registration fee includes: T-shirt,waterbottle, cap, back-packand admin fee)

2.I hereby confirm that all medical information given is accurate and that my child’s medical condition is such that he can comfortably take part in sport.

3.I understand that the purpose of Matie Rugby Academy: Schools is to improve Rugby skills in general.

4.I understand that the coaches of Matie Rugby Academy: Schools are not medical doctors and are not trained to make medical diagnoses, give treatment and/or advice.

5.In the event of an injury or any medical problem, the coaches must be informed. I further give permission that in case of an emergency, if necessary(if the parent or guardian cannot be reached), the coaches of Matie Rugby Academy: Schoolsmay call a doctor, ambulance or hospital.

6.I hereby undertake that no claim of any sort, personal or on behalf of my child or ward, will be made against Matie Rugby Academy: Schools or the University of Stellenbosch (US), or any employee,official, agent, or appointee of the US or Matie Rugby Academy: Schools and in no way hold Matie Rugby Academy: Schools or the University of Stellenbosch (US), or any employee,official, agent, or appointee of the US or Matie Rugby Academy: Schools liable for any loss or damage of any nature to me personally or that of my child or ward, directly or indirectly as a result of my child or ward’s participation in coaching sessions of Matie Rugby Academy: Schools. I further undertake to exempt Matie Rugby Academy: Schools or the University of Stellenbosch (US), or any employee,official, agent, or appointee of the US or Matie Rugby Academy: Schools from liability consequent upon any loss or damage my child or ward may suffer, wether loss or damage is directly or indirectly consequent of my child or ward’s participation in coaching sesions of Matie Rugby Academy: Schools.

7.I agree that this undertaking is fully binding to me.

I______(parents name) parent/guardian of ______(child/wards name and age group) accepts the preceding terms and condition as set out by Matie Rugby Academy: Schools.

______

Signature of parent/guardian

Witness:

1 ______

2 ______

Date: ______