SOUTHWEST WRESTLING CLUB WAIVER

This is the registration for enrollment of ________________________________ (athlete's name--please print) in the Southwest Wrestling Club for the year 2008. I grant permission to the club director, coaches and assistants of the club to act on my behalf for said minor in granting permission for evaluation/treatment of minor medical problems. I understand that should a major medical problem arise, an attempt will be made to notify me by telephone. In the event that I cannot be reached, I hereby give my consent to such medical treatment as deemed necessary by a licensed physician, such as x-ray examinations and anesthesia to be rendered to said minor. In addition, I hereby release the Southwest Wrestling Club and its staff from liability and claims for damages my son/my daughter may sustain while participating in the Southwest Wrestling Club.

I hereby certify that I have read and fully understand this authorization.


Participant or Parent/Guardian Signature (if 18 or under or still in High School or below)


____________________________________________Date signed____________

Allergic reactions to:______________________________________________

Medications currently taking: _________________________________________________


Any past illnesses or other information that would be useful in the event medical treatment is necessary:

_______________________________________________________________


Information;

Name _________________________________________


Parents or Legal Guardian _______________________________________________


Address _____________________________________________________________________
(be sure to include zip and city if other than Lincoln)

Phone# __________________________


Emergency Phone# ________________________


Insurance Company_________________________________
Policy #______________________


Age________

Grade ________