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Elementary Sign-up (K-6)

Wrestler's Name *

Date of Birth *

Total Years Wrestling

Father (Guardian) *

Mobile Phone *

Email Address

Mother (Guardian) *

Mobile Phone *

Email Address

Emergency Contact

Please indicate another person to call if an accident occurs and we are unable to reach you:

Emergency Contact: Full Name *

Mobile Phone *

Medical Information

Insurance Company *

Group #

Family Doctor

Office Number

Is your child presently on medication? *YesNo

If yes, please list medication(s)

Drug Sensitivities

Other Allergies

Date of your child's last complete physical examination by a medical doctor *

SIGN ONLY ONE BELOW!!!

Please read the alternative statements below and sign under the ONE that you choose.

1. 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.

Parent/Guardian Name

Date Signed

2. 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 cost related to such treatment.

Parent/Guardian Name

Date Signed

Wrestlers USA Wrestling Card No.

Name of Club *

Consent *

By reading the document below (Page 2), the participant and parent (guardian) acknowledges having read and understood its meaning and contents. You do not need to fill out any of the information on the link below, this is for reference to the verbiage that you will consent to in this form.

https://www.usawmembership.com/images/usa_wrestling_event_consent_waiver.pdf

Participants Name *

Date Signed *

Parent (Guardian) Name *

Date Signed *

Medical History

Please select the correct answer, all information will be confidential

1. Are you allergic to any general medication (aspirin, sulfa, penicillin, etc.)? *YesNo

If so, please indicate what medication(s)

2. Are you now on any prescribed medication on a permanent or semi-permanent basis? *YesNo

If so, please indicate what medication(s) and why prescribed?

3. Have you ever had an epileptic seizure or been informed that you might have epilepsy? *YesNo

4. Have you ever been treated for diabetes? *YesNo

If so, please indicate the types of insulin or pills you use.

5. Has a medical doctor ever told you that you were anemic or had sickle cell anemia? *YesNo

6. Do you have, or have you ever had high blood pressure? *YesNo

If so, list any medication(s) for it that you take regularly.

7. Do you have, or have you ever had any of the following diseases? *NoHeart Disease (rheumatic fever)Liver Disease (hepatitis)

8. Have you ever been informed by a medical doctor that you have asthma? *YesNo

If so, list any medication(s) for it that you take regularly.

9. Do you presently have an unrepaired hernia? *YesNo

10. Have you ever been "knocked out" or experienced a concussion during the past 3 years? *YesNo

If so, give latest concussion date:

11. If you have experienced a concussion within 3 years, did the attending physician have you stay overnight in a hospital? *YesNo

If so, give hospital date:

12. Have you ever had an injury to your neck involving nerves, vertebrae (bones), or discs that incapacitated you for a week or longer? *YesNo

If yes, give the dates of injury

13. Do you wear any dental appliance? If yes, select the appropriate appliance: *NoPermanent bridgePermanent crown or jacketBraces full plateRemovable partial platePermanent retainerRemovable retainer

14. Do you wear contact lenses during competition? *YesNo

15. Have you had a fracture during the past 2 years? *YesNo

If so, indicate which bone was broken and the date it happened.

16. Have you had a shoulder dislocation, separation or other should injury in the past 2 years that incapacitated you for a week or longer? *YesNo

If yes, give the dates of injury

17. Have you ever had surgery to correct a shoulder condition? *YesNo

If yes, give the dates of surgery

18. Have you ever had an injury to your back? *YesNo

19. Do you experience pain in your back? If yes, indicate frequency: *NoSeldomOccasionallyFrequentlyWith vigorous exerciseWith heavy lifting

20. Have you injured your knee during the past 2 years with sever swelling as a result? *YesNo

21. Have you ever been told that you injured the ligaments and/or cartilage of either knee? *YesNo

22. Have you ever been advised to have surgery to correct a knee problem? *YesNo

If so, has the surgery been completed? Indicate a date too.

23. Have you experience a severe sprain of either ankle during the past 2 years? *YesNo

24. Have you had any injury to your foot or toes in the past 2 years? *YesNo

If so, explain:

25. Do you have any chronic conditions that have not been mentioned above? *YesNo

If so, explain:

Registration Fee

Please provide payment information in the next section to register your child for the season.

Club Registration *$150.00

Add-onsRent Singlet - $15.00Rent Wrestling Shoes - $15.00Purchase Singlet - $50.00Chili Tickets (30 total) - $0.00

Wrestler T-Shirt size? *

Wrestler Singlet Size?

Total Due:

$

Name on Card *

Mobile Phone *

Email Address (Receipt) *Receipt will be sent to this email.

Credit / Debit Card *

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Contact us

Mike Barrow – President

620-755-6041

[email protected]

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