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Wrestler’s Name __________________________________
Please indicate another person to call if an accident occurs and we are unable to reach you:
Date of Birth ____________________________
Parent/Guardian Name _____________________________ Relationship ____________________________
Address ____________________________________________________________________________________
Home Phone ________________________________ Work Phone ________________________________
Email Address(es): _____________________________, _______________________, ______________________
Name __________________________________________ Phone No. ______________________________
Is your child presently on medication? _________________________ If yes, please list medication(s):
____________________________________________________________________________________
Please read the alternative statements below and sign under the one that you choose. Sign only one!
1. If my child needs medical attention, it is my wish that I be contacted before any medical procedures are taken on my child, unless immediate treatment is necessary to save my child’s life or to prevent permanent injury.
Parent/Guardian Signature ____________________________________ Date Signed _______________
2. If my child needs medical treatment while participating, it is my wish that the treatment be started while efforts are being made to contact me. So that treatment is not delayed, I consent to any medical procedures that the physician believes are needed, on the understanding that efforts to contact me will continue to be made. I accept responsibility for all costs related to such treatment.
Parent/Guardian Signature ____________________________________ Date Signed _______________
Drug Sensitivities ______________________ Other Allergies __________________________________________