Individual Registration

Registrant Information

Name:


First	Last

Address:

City, State Zip:

Phone:

Email:

Grade:

Birth Date:

Player Cell Phone:

Cell Phone Provider (Sprint, Verizon, etc.):

Parent(s) / Guardian(s):

Mother/Guardian E-mail:

Father/Guardian E-mail:

Mother/Guardian Cell Phone:

Cell Phone Provider (Sprint, Verizon, etc.):

Father/Guardian Cell Phone:

Cell Phone Provider (Sprint, Verizon, etc.):

Parent Day Time Phone:

Other Emergency Contact:

Emergency Contact Number:

CIPP Number:

Comments:

Club Dues

$250.00

New Member

Includes club fees, warm-ups, and duffle bag.

$160.00

Returning Member

Includes club fees only.

Please continue to the payment page.

Please make out checks to the Myers Park Rugby Club. The check can be sent to the following address or turned in at practice.

Myers Park Rugby Club
P.O. Box 12362
Charlotte, NC 28220