2020-2021 Youth Registration

Youth Wrestling Registration 2021-22

Athlete Info
Name*
Athlete First Athlete Last
Date of Birth*
MM slash DD slash YYYY
USA Card Number (Leave Blank if you do not have a USA Card #)
USA card is an insurance card required for participation in our club. The club purchases your card and once you have a number, each year the card is renewed the number remains the same.
School Attended by Athlete*
Grade Level*
T-shirt Size*
Parent Guardian Info
Primary Parent Gaurdian*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Secondary Parent Gaurdian (if needed)
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Phone
Medical Information
Insurance Company*
Insurance Policy Number*
Family Doctor*
Is your child on any medications*
- Yes
- No
Please list the medications*
Does your child have any drug sensitivities or food allergies?*
- Yes
- No
Please List*
Approximate Date of last physical exam by a doctor*
MM slash DD slash YYYY
Medical Treatment (please check just one)*
Please read the alternative statements below and select the statement you prefer for your son or daughter.
- If my child needs medical attention, it is my wish that I am contacted before any medical procedures are taken on my child, unless immediate treatment is necessary to save my child’s life or to prevent permanent injury.
- If my child needs medical treatment while participating, it is my wish that the treatment is started while efforts are being made to contact me. So that treatment is not delayed, I consent to any medical procedures that the physician believes are needed, on the understanding that efforts to contact me will continue to be made. I accept responsibility for all costs to such treatment.
Athlete Registration*
Price:
If any family registers more than 2 athletes (each one has to be done separately) from same household, money will be refunded through PayPal for all athletes over 2 (max. $150 per household)
This page is unsecured. Do not enter a real credit card number! Use this field only for testing purposes.
Payment Method

MasterCard
Visa
Supported Credit Cards: MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

2020-2021 Youth Registration

Youth Wrestling Registration 2021-22

Athlete Info

Parent Guardian Info

Medical Information