THE EAST SIDE GRAPPLING CLUB WAIVER AND INFORMATION SHEET

This is the registration for enrollment of ________________________________ (athlete’s name) in
the East Side Grappling Club for the year 2006. 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 East Side Grappling Club and its staff from
liability and claims for damages my son/my daughter
may sustain while participating in the East Side
Grappling 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 ________



__________________________________________________