Bounce Back WW LLC Detailed Registration Form

Athlete's Name*

First NameLast Name

Athlete's Name #2

First NameLast Name

Birth Date (Athlete#1)*

MonthDayYear

Birth Date (Athlete#2)

MonthDayYear

Grade (Athlete#1)*

Grade (Athlete#2)

Weight (Athlete#1)

Weight (Athlete#2)

MaleFemale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Parent/Guardian #1 Name*

First NameLast Name

Parent/Guardian #2 Name

First NameLast Name

Home Number-Parent/Guardian#1*

Format: (000) 000-0000.

Home Number-Parent/Guardian#2

Format: (000) 000-0000.

Cell Number- Parent/Guardian#1*

Format: (000) 000-0000.

Cell Number-Parent/Guardian#2

Format: (000) 000-0000.

E-mail-Parent/Guardian#1*

example@example.com

E-mail-Parent/Guardian#2

example@example.com

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Format: (000) 000-0000.

Alt. Phone Number

Format: (000) 000-0000.

Does the athlete (s) have any allergies, chronic illness, or medical conditions? If yes, please describe and name which athlete if signing up multiple children.*

Is the athlete prescribed an inhaler? If yes, please explain any instructions and name which athlete if signing up multiple children.

Name of Medical Insurance Carrier:

Policy Number:

Group Number:

Policy Holders Name:

Policy Holder's Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Options

Drop In Fee for 1 Day of Wrestling Instruction

$20.00 Quantity

Wrestling Instruction for 1 Month of Classes

$100.00 Quantity

Summer Camp 1 Week Fee

$75.00 Quantity

Summer Camp 1 day Drop In Fee

1 day at Summer Camp- Incl. Lunch

$25.00 Quantity

Summer Camp 1 week (2 children)

$125.00 Quantity

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Bounce Back WW, LLC. In exchange for the acceptance of said child’s candidacy by Bounce Back WW, LLC, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Bounce Back WW, LLC and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from camp activities, practices or sessions.

In case of injury to said child, I hereby waive all claims against Bounce Back WW, LLC including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including wrestling. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Bounce Back WW, LLC and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Date*

Date

Signature*

Registration

Athlete Information

Payment Methods