IRTC Clinic Registration Form

IRTC x Rochelle Wrestling Club Clinic Registration Form

CLINICIAN - MIKE POETA
Date: Sunday, Sept 28, 2025

Time: 1:00 PM - 4:00 PM

Location: 1401 Flagg Rd

Rochelle, Illinois

Door 15

Ages: 3rd - 12th Grade

Please Read:

MUST HAVE ACTIVE USAW CARD!

Please make sure you renew your card prior to the clinic.

-Schedule:

Check-In 12:30PM

Clinic 1PM-4PM

-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 - Clinic Fee Due at Check-In via Cash, Check or Venmo to Rochelle Wrestling Club
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 Rochelle Wrestling Club Clinic Registration Form

Wrestler Information

Emergency Contact Details

Medical Information

Payment Details

Acknowledgment, Authorization, and Waiver