Child’s Name:						USA Card #:
Birth Date:	Grade:		Approx. Weight:			Wrestling Exp(Yrs):
Special Medical Concerns:
Doctor’s Name:								Phone:
Parent(s)/Guardian(s):
Address:
City:				Zip:	Home Phone:
Cell Phone #1:       Cell Phone #2:		E-Mail (important)       E-Mail #2
Put me in the directory to be shared with other club members							Yes		No
Name and phone of Emergency Contact (not living with you:

 

PARENTAL RELEASE FROM LIABILITY AND REQUEST FOR EMERGENCY MEDICAL ADMINISTRATION

 

As parent or guardian, I give my permission for       to participate in the San Diego Kings Youth Wrestling Club for the current season.  I hereby authorize my child to participate in said activity and hereby release and waive any claim, demand, cause, action, assertion or liability against the San Diego Kings Youth Wrestling Club it’s officers, coaches, chaperones and the San Diego School District, which may result from any accidents or happenings occurring during or as a result of such activity.  Further, if emergency medical administration is needed by my child during or resulting from said activities, I authorize any of the chaperones to authorize any licensed physician or surgeon to administer said emergency medical attention.  I further waive any claim, demand, cause, action or assertion of liability against administrating emergency medication attention.

 

Signature of Parent/Guardian ________________________________________________________________________________

 

Date                                   Relationship to Child      

 

 

 

 

 

 

 

 

 

(for administrative use only)

 

Amount Paid        $_____________________   Cash    /    Check           Check #  ______________              USA Card Given ______________

 

Proof of birth date provided for file:  Yes    /    No