South Fayette Take Down Club Youth Wrestling Authorization/Sign-Up Form

NAME:

AGE:

BIRTHDATE:
/ /
ADDRESS:

ADDRESS:

CITY:

STATE:	ZIP:

PARENT/GUARDIAN NAME:

FALL 2003 GRADE:	WEIGHT:

STATEMENT OF PERMISSION BY PARENT OR LEGAL GUARDIAN
I/We as parent(s) and/or guardian(s) give permission for my/our son/daughter to participate in all activities, including fund-raising activities necessary to meet our financial obligations and to benefit from the instruction and opportunity for the enjoyment my child will receive. I also understand and agree with the following stipulations: ASSUMPTION OF RISK: Wrestling is a contact sport. While serious injuries are rare, they are nonetheless possible. As a responsible parent or guardian I understand and agree that the risk of injury is fully the responsibility of the family of the participant. Payment for any medical treatment that any injury may necessitate is the responsibility of the participant's family and the family's insurance carrier. I/we also relinquish responsibilities form the South Fayette School District, South Fayette Take Down Club, coaching staff, and anybody involved in association business for any personal injury to the above mentioned child. The association has insurance coverage for each child registered.
KNOWN HEALTH PROBLEMS/ ALLERGIES:

INSURANCE COMPANY:

POLICY#:

PHYSICIAN:

PHONE:

I/We are also responsible for the return of all wrestling equipment/uniform assigned to my child, and if not returned, will pay the full invoice amount of the same. I understand that at the time of distribution, a $30.00 deposit is required from each wrestler. This deposit will be refunded once the uniform is returned to the South Fayette Take Down Club at the end of the wrestling season. In order to provide an excellent program for our children, this association needs help from as many parents/guardians as possible. Please select from the following below where you may be able to provide help for our annual wrestling tournament.

SIGNATURE OF STUDENT:
_____________________________________________________
SIGNATURE OF PARENT/GUARDIAN:
_____________________________________________________
ADDRESS (IF DIFFERENT FROM STUDENT'S):

E-MAIL ADDRESS:

PHONE: