Rugby Academy Student Information Form

Premier Rugby Academy Student Information Form

For the 2023-2024 school year

"*" indicates required fields

Participant Information

Name*

First Last

Male/Female/Other*

Current Grade*

Date of Birth*

Student's Email*

Primary Parent Contact Information

Primary Parent Name*

First Last

Primary Contact Telephone*

Primary Contact Email*

Primary Contact Work Phone

Primary Contact Home Phone

Primary Contact Cell Phone

Primary Contact Address*

Street Address City Postal Code

Other Parent Contact Information

Other Parent Name

First Last

Other Parent Telephone

Other Parent Email

Other Parent Work Phone

Other Parent Home Phone

Other Parent Cell Phone

Other Parent Address if different from above

Street Address City Postal Code

Additional Information

Student's Current School*

School Location*

ie: West Vancouver, North Vancouver, etc.

School Attending this upcoming September*

Name of school if "Other" selected above

Current Rugby Experience (Beginner, Intermediate, Advanced)*

Years of Rugby Experience (1, 2, 3, 4, 5, etc.)*

Current Position (Forward, Back, etc.)*

Where Played (Club or Representative)*

2019-2020 Capilano RFC member?

Yes

Coach*

Coach Phone*

Coach Email*

Please tell us why you would be a good candidate for this program.*

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Premier Rugby Academy Student Information Form

For the 2023-2024 school year

Participant Information

Primary Parent Contact Information

Other Parent Contact Information

Additional Information