Name __________________________________________________________
Home Address __________________________________________________
City ____________________________________ State ____ Zip_________
Email ______________________________________________
Phone: Home _____/ _____________________ Cell _____/_____________
Parent/Guardian’s Name ______________________ Phone _____/ ____________
Email __________________________________________________________
Date of Birth ____/____/____ Weight Class ______ Years of Experience _____
USA Wrestling Card # _________________________ T-shirt Size ___________
AAU Card # _________________________________ Short Size ___________
This MUST be completed in order to process any application!
Health Insurance Company _______________________________________
Policy Number(s)_________________________________________________
Family Physician _________________________________________________
1. Does the participant have any significant allergies? Yes/No
_____________________________________________________________
2. Will the participant be taking any medications while attending the
session? Yes/No If yes, what (name and dose).
_____________________________________________________________
Are there special considerations with regard to this medication?
Yes/No (Please attach additional instructions as necessary.)
3. Does the participant have any current or past history of a significant
health problem (eg, diabetes, epilepsy, etc)?
Yes/No If yes, please describe.
________________________________________________________________
I approve of my child’s attendance and travel with the Chattanooga Wrestling Club. I certify that within the past year he/she has had a physical examination and that he/she is in good health and able to participate in all Chattanooga Wrestling Club activities. If medical attention is required for illness or injury while attending Chattanooga Wrestling Club events and practices or on travel to events, I give my permission for such care and I hereby waive and release the Chattanooga Wrestling Club staff of all liability for any illness or injuries which may occur. I understand that any wrestler who does not abide by Chattanooga Wrestling Club rules and regulations is subject to dismissal without reimbursement, and that damage to facilities will be assessed to those responsible. I also understand that it will be my responsibility to transport my son/daughter back from any event due to misbehavior.
______________________________________________________________________________
Signature Parent/Guardian Signature Date