Red Dirt Rugby Holiday Program Registration Form

Red Dirt Rugby Holiday Registration

Complete the form below to sign up for our holiday skills program being run in Gympie. Please bring a mouthguard and water for your child/children.
Name (child 1)

First NameLast Name
Name (child 2)

First NameLast Name
Name (child 3)

First NameLast Name
E-mail
Phone Number:

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState

Postal Country
Birth Date:

MonthDayYear
Select session

Day 1 $70Day 2 $70Full program $130
Please make payment to:

Red Dirt Rugby Academy

BSB: 923-100

Account: 38167693

Reference: Your surname

Cost: $130 to be paid in full before the start of the program.

Contact Red Dirt Rugby Academy if you would like to discuss payment options.
- Risk and liability
  
  I agree to assume all risks and responsibilities surrounding my (or my child's) participation in the program under the instruction of Red Dirt Rugby Academy coaches. I understand that similar to all sporting activities, there is a risk of damage to personal property, injury, serious injury, permanent disability, paralysis or death which may result from causes beyond the control of, and without fault or negligence of Red Dirt Rugby Academy, its officers, agents, or employees, during the period of my (or my child's) participation.
  
  I understand completely the above agreement and agree to be bound thereby.
- Photo Release
  
  Red Dirt Rugby Academy has my permission to use my or my child’s (named above) photograph publically to promote the academy. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.
I have read, understood, and accepted the risk and liability.I have read and understood the photo release and give permission for my child's photograph to be taken.
Where did you hear about us?

A Friend or colleagueGoogleFacebookNews ArticleInstagram
Privacy Policy

Red Dirt Rugby Academy will not give your details to any third-party, but the Academy will send you a newsletter to keep you updated on its programs. It may include information from sponsors from time to time.
I have read, understood, and accepted the PRIVACY POLICY.
Thank you for submitting your registration.
Medical Form
PLAYER 3 NAME

First NameLast Name
PLAYER 1 NAME

First NameLast Name
PLAYER 2 NAME

First NameLast Name
PARENT/GUARDIAN'S NAME

First NameLast Name
Phone Number

Area CodePhone Number
Emergency contact

First NameLast Name
Emergency number

Area CodePhone Number
Please list any medical conditions your child has (asthma, anaphylaxis)
What medication does your child take?
Will training aggravate your child's condition?

YesNo
Please list relevant medical details
Medicare number
Name on card (child one)
Name on card (child two)
Name on card (child three)
Private health fund
Health fund number
NOTE: It is the parents' responsibility to ensure that the player is adequately covered for Medical, Hospital, Dental and Personal Accident & Injury Insurance. Red Dirt Rugby Academy will not accept financial liability for such expenses if they should arise. Red Dirt Rugby Academy has a Code of Conduct, which will be sent to parents/players and read out at the beginning of each training session. Players are expected to abide by this to create a safe environment.
I understand and accept the above

Yes
Medical Authorisation: I hereby authorise the obtaining, on my behalf, such medical assistance as my son/daughter may require in the event of accident or illness and guarantee to meet any costs incurred. I authorise the administering of anaesthetic if the medical officer attending deems this necessary.
I understand the medical authorisation

Yes

Red Dirt Rugby Holiday Registration

Risk and liability

Photo Release

Privacy Policy

Medical Form