SEATTLE RUGBY FOOTBALL CLUB

In connection with participation on the Seattle Rugby Football Club, I authorize the Seattle Rugby Football Club to consent to any X-ray examination, any anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and to be rendered under, the general or special supervision of any physician or surgeon licensed under the provisions of the Medicine Practice Act, whether such diagnosis or treatment is rendered at the office of the physician, or at a hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, and is being given to provide the Seattle Rugby Football Club the ability to give specific consent to any and all such diagnosis, treatment, or hospital care with the aforementioned physician in the exercise of her or his best judgment may deem advisable. This consent is given with the caveat that the need for treatment is immediate and I am not of sound mind and body . I understand that I assume all liabilities and expenses for the above. I waive all claims against the above referred to adult, physicians, hospitals and their employees, ambulatory care, etc., in connection with the decision for immediate care.

This authorization is only valid from July 1, 2006, to June 30, 2007, inclusive.

The following is provided:

Home phone: ______________________________ Work Phone: ______________________________

Alternate point of contact: Name: ______________________________ Phone #: ________________________

The undersigned has at least $100,000 in medical expense insurance coverage.

The undersigned guarantees that all information provided is true and correct.

Signature: _____________________________________________________________ Date: _________________________

Printed Name: _________________________________________________________