TKWC Registration Form 23/24

Wrestler's Full Name

Birth Date

Date

Grade

Address

Apt #

City

State

Zip

USA Wrestling Card

Upload USA Wrestling Card Screenshot

Guardian Cell Phone #

Format: (000) 000-0000.

Gender

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

Parent Name

Phone 1

Format: (000) 000-0000.

Cell Phone

Format: (000) 000-0000.

Parent Name

Phone 1

Format: (000) 000-0000.

Cell Phone

Format: (000) 000-0000.

Please list any allergies the wrestler has:

Is the wrestler currently on any medication?

Has the wrestler been diagnosed with a concussion?

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 Total Kaos Wrestling Club training sessions, events, or competitions from 09/01/2024 to 08/31/2025 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 Total Kaos Wrestling Club Wrestling Inc., the employees and associated personnel of the organization, and affiliated organizations against any claim by or on behalf of the wrestler named above as a result of that wrestler's participation in Total Kaos Wrestling Club programs and/or being transported to or from the same, which transportation I hereby authorize.

Initial:

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 name and image in promotional publications for Total Kaos Wrestling Club.

By signing below, I acknowledge that I have read, understand, and accept the above contractual agreements.

Parent/Guardian Name (Please Print)

Parent/Guardian Signature

Date

Relationship to wrestler: