Adaptive Athletics at University of Houston
Wheelchair Rugby Camp Registration Form
Name:________________________________________________________
Address:______________________________________________________
Home
Phone:________________________________________________________
Mobile:_______________________________________________________
Email:________________________________________________________
Gender:  Male  Female Date of Birth:__________________________
School Attending (if applicable): _________________________________
Please tell us about your disability:
__________________________________________ ___________________
__________________________________________________________________
______________________________________________________ __
Your Emergency Contact:
Name:___________________________________________________
Address:_________________________________________________
Home Phone:_____________________
Mobile:__________________________
Email:___________________________________________________
How did you hear about the camp?
_______________________________________ ______________________
__________________________________________________________________
________________________________________________________
Wheelchair Rugby Experience:
Skill Level:
________________________________________________________
Rugby Classification (if known):
______________________________________
List of other sport participation:
______________________________________
Current Team Names:
______________________________________________
Will you need a rugby chair?  Yes  No
Will you need transportation to and from the Houston airport? Yes  No
Are you interested in a tour of the University of Houston?  Yes  No
What specific interest do you have at the collegiate level?
_____________________________________________________________
__________________________________________________________________
______________________________________________ __________
Confidential Medical Details
The information given may be vital in an emergency. It will remain confidential
but may be given to a third party in the event of an emergency e.g. emergency
staff
Doctor’s Name:
__________________________________________________________
Doctor’s Phone Number:
__________________________________________________
2 Please be aware of my physical and/or medical conditions
(check for those that apply)
Asthma

Speech

Weak limb

Mobility difficulties

Autism

Diabetes type 1

Heart condition

Diabetes type 2

Other please state below:
_____________________________________________________________
__________________________________________________________________
______________________________________________ __________
Other physical and/or medical conditions not covered above:
_________________________________________ ____________________
__________________________________________________________________
______________________________________________ __________
Please be aware of my food intolerances or other allergies i.e. hay fever,
penicillin etc. (please list)
_____________________________________________________________
__________________________________________________________________
_________________________________________ _______________
Are you a Vegetarian?  Yes  No
Are you currently taking any medication?  Yes  No
Please detail Drug name, Dose and Frequency below:
Name:
Dose:
Frequency:
___________________________ ____________ ____________
___________________________ ____________ ____________
___________________________ ____________ ____________
___________________________ ____________ ____________
___________________________ ____________ ____________
Who administers your medication?
_________________________________________
3 Do you take any medication that might be required in case of an emergency?
 Yes  No
If yes, please give details of emergency medication:_________________
____________________________________________________________ ______
__________________________________________________________________
___________________________________________________
Will you need a shower chair?  Yes  No
Please tell us – is there any other support you may need? _____________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
______________________________________________
Please tell us about your wheelchair/rugby chair:____________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
______________________________________________ Do you have any Social Media we can tag you in?  Yes  No
If so, please provide an ID: ______________________________________ _____
__________________________________________________________________
________________________________________________________
4 Publicity and Photography
Occasionally the camp may take and use images of youth players to promote and
report on the camp in the local press, website etc.
I agree for camp officials to refer to my child’s name in reports given to the
local press/camp publications/website
I agree for camp officials to take pictures of my child and use in local
press/camp publications/website
I agree for camp officials to video record my child playing rugby to use in the
local press/camp publications/website
Data Protection Act 1998
Please sign below: I agree that Adaptive Athletics at University of Houston may
hold the personal information about my child that I have given for the purpose
of administering the registration of players.
Signature (Parent/Guardian if
minor):______________________________Date:_____________________
Payment:
Please make all checks out to:
University of Houston
Memo: Adaptive Athletics
3855 Holman St.
Garrison Room 104X
Houston, TX 77204
Registration fee: $250.00
Deadline for Early Register: May 7 th 2014
Deadline for Late Register: May 21 st 2014 ($75 Late fee to be applied)
**If you are a participant in the local Houston area, please contact:
Dr. Mike Cottingham: mcotting@central.uh.edu
James Megna: jamesbmegna@yahoo.com
Adaptive Athletics @ UH Registration:
adaptiveathleticsuh.register@gmail.com
Registration fees include:
Housing
Meals
Transportation
Camp T-shirt
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