Each club member must have a current USA card to practice or compete  

Name:                                                                                          USA Card#:                           

Address:                                                                                                                                            

Phone:                                     Birth Date:                                # of years Wrestling                   

School:                                                                                   Grade:                                                

PARENTAL INSTRUCTION CONCERNING MEDICAL TREATMENT 

Father’s Name:                                                                 Work Phone:                                                 

Mother’s Name:                                                                 Work Phone:                                                 

Emergency Contact/Relationship:                                     Phone:                                               

Doctor’s Name:                                                                            Phone:                                               

Insurance Provider and Policy #:                                                                                                          

Is your child presently on medication?                If yes, list all medications:                         

Please list all drug sensitivities or allergies:                                                                             

PLEASE READ CAREFULLY BELOW AND SIGN ONE CHOICE ONLY 

A:  If my child needs medical treatment while participating in wrestling, it is my wish that I be contacted before any medical procedures are done on my child, unless immediate treatment is necessary to save my child’s life or prevent permanent injury.

  Signature of Parent/ Guardian:                                                       Date:             

B:  If my child needs medical treatment while participating in wrestling, it is my wish that the treatment begins 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 will continue to be made to contact me.  I accept responsibility for all costs related to such treatment.

  Signature of Parent/Guardian:                                                   Date: