A-TEAM WRESTLING CLUB WAIVER

Wrestler's Full Name

Birth Date

Date

Grade

Address

Street Address Line 2

CityState

Zip

Parent/Guardian Name

Parent Cell

Parent/Guardian Name

Parent Cell

YESNO

If yes, what is the card number?

In an emergency when parent/guardian cannot be reached, please contact the following:

Contact Name

Cell Phone

Format: (000) 000-0000.

Contact Name

Cell Phone

Format: (000) 000-0000.

Please list Allergies the wrestler has:

YESNO

If yes, list:

YESNO

If yes, when and how severe?

Please list other medical conditions

Physician Name

Physician Phone Number

Format: (000) 000-0000.

Medical Insurance Company

Phone

Format: (000) 000-0000.

Policy Holder's Name

Policy Member I.D. #

I hereby give my consent for the above-named wrestler to participate in any A-Team Wrestling Club run training sessions, events, and/or competitions from I recognize the possibility of physical injury associated with wrestling, which may include but is not limited to paralysis, permanent mental disability, and death, and hereby release, discharge, and otherwise indemnify A-Team Wrestling Club, the employees, associated personnel of the organization, affiliated organizations, property, and property owners against any claim by or on behalf of the wrestler named above as a result of that wrestler's participation in A-Team Wrestling Club programs and/or being transported to

or from the same, which transportation I hereby authorize. Initial:

Initial (Parent's initials)

I hereby give my consent to have an athletic trainer, coach, emergency medical technician, nurse, medical treatment facility, and/or doctor of medicine or dentistry or associated personnel provide the wrestler with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I understand treatment for injury will be based on information provided herein. I hereby authorize emergency transportation of the wrestler to a medical treatment facility should an individual listed above consider it to be warranted. Initial:

I hereby authorize the use of the above-named wrestler's image and name in promotional publications for A-Team Wrestling Club. By signing below, I acknowledge that have read, understand and accept the above contractual agreements.

Initial (Parent's initials)

Date

Wrestler's Signature

Parent/Guardian Signature

Date