Wrestler's Name
*
First Name
Last Name
School
Grade
Weight
Date of Birth
*
MM
DD
YYYY
Years of Wrestling Experience - at least 3yrs required
*
3
4
5
6+
Email Address
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent/Guardian Name
*
First Name
Last Name
Phone
*
(###)
###
####
Emergency Contant (other than parent)
*
First Name
Last Name
Emergency Contact Phone
*
(###)
###
####
Medical Insurance
*
Medical Insurance Policy Number
*
Primary Care Physician
*
Primary Care Physician Phone
*
(###)
###
####
Is your child currently on medication?
*
If YES, please list all medications
Does your child have any allergies/health problems?
*
If YES, please list all allergies/health problems
Has your child had any surgeries or hospitalizations?
*
If YES, please list all surgeries/hospitalizations including year
Youth Athletic Waiver and Release of Liability
*
In consideration with allowing the child whom I am considered to be the legal parent or guardian of, to participate in the Riggs Elite Wrestling Club (REWC), related events and activities, the undersigned acknowledges, appreciates, and agrees that:
* The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, while particular rules, equipment, personal discipline may reduce this risk, the risk of serious injury does exist; and,
* I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my child's participation.
* I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove my child from participation and bring such to the attention of the nearest club employee immediately.
* I, for myself and on behalf of my heirs, assings, personal representatives and next of kin, RELEASE AND HOLD HARMLESS the Riggs Elite Wrestling Club (REWC), other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event ("RELEASES"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.
* I, on behalf of my participating child consent that the photographs, artwork, audio, video, or writing that is documented may be used by the Riggs Elite Wrestling Club (REWC), it's assigns or successors, in whatever may the desire, including television, CD-ROMS, web page, publications, and any other form for the storage, retrieval and reproduction of information, images; furthermore, I hereby consent that such information, photographs, videos, and the plates and/or tapes from which they are made shall be their property and they shall have the right to sell, duplicate, reproduce and make other uses of such information, photographs, videos, recordings, and plates as they may desire free and clear of any claim whatsoever on my part.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
I DISAGREE, my child will not participate in the REWC program.
Parent/Guardian Electronic Signature
*
Parent/Guardian name - person completing form.
Thank you for your registration.
Please bring your payment to your first practice.
Thank you,
Riggs Elite Wrestling Club