IRTC Clinic Registration Form

IRTC x Mattoon Wrestling Club Clinic Registration Form

CLINICIAN - MIKE POETA
Date: Friday, July 18, 2025

Time: 5:00 PM - 7:00 PM

Location: 500 Dewitt Ave

Mattoon, Illinois

Ages: Kindergarten - 12th Grade

Please Read:

-Schedule:

Check-In 430PM

Clinic 5PM-7PM

-Please bring wrestling shoes & water bottle
Wrestler Information
Camper Name*

First NameLast Name
Age*
Weight*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Name*
Grade*
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Phone Number*

Area CodePhone Number
Parent/Guardian Email*
example@example.com
Emergency Contact Details

If parent/guardian cannot be reached.
Contact Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Medical Information
Please let us know if you have any allergies, existing illnesses or any medical conditions.
Payment Details

$50 ($30 for MYWC Summer Season Wrestlers) - Clinic Fee Due at Check-In via Cash, Check or Venmo
Acknowledgment, Authorization, and Waiver
This camper has my authorization to engage in the activities of the Illinois Regional Training Center and it's entities.

I allow taking photography of this camper that can be used for Illinois Regional Training Center portfolio or advertising.

I authorized Illinois Regional Training Center to apply judgment in regards to medical assistance in the event of an accident, injury, or illness if they are unable to contact the parent/guardian. I allow them to apply first aid, medical or surgical diagnosis and treatment as necessary.

I allow Illinois Regional Training Center to provide or administer the medication or supervise in self-administration.

I release Illinois Regional Training Center and any of its coaches, staff, and manager for any responsibility in case of accident, illness, or injury during this camper's enrollment.
Date Signed*

MonthDayYear
Date
Parent/Guardian Signature*

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Illinois Regional Training Center

Champaign, Illinois - www.illiniRTC.com
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IRTC x Mattoon Wrestling Club Clinic Registration Form

Wrestler Information

Emergency Contact Details

Medical Information

Payment Details

Acknowledgment, Authorization, and Waiver