Championship Takedowns

Wrestling Camp
@
Leonardtown High School
Monday July 27, 2015 Thursday July 30, 2015
(9:00AM 4:00PM)
Last Name_______________________First Name______________________Middle___
Address_________________________________________________________________
City____________________________State_________Zip_________Phone__________
Date of Birth__________________________________
E-Mail Address:__________________________________________________________
In Case of Emergency:

Name_______________________Relationship__________
Address_________________________________________
City____________________State______Zip___________
Phone__________________(W)___________________(H)

Medical Insurance Company________________________Policy #__________________

Subscribers Name________________________________
Medical Treatment Authorization: I hereby authorize the clinical staff and the local
emergency medical responders to provide care and medical treatment as necessary to my
son/daughter ________________________. I understand that the consent and
authorization herein granted do not include major surgical procedures and are only valid
during camp. In the event that an illness or injury would require more extensive
evaluation, I understand that every reasonable attempt will be made to contact me.
However, in the event of an emergency, and if I cannot be reached, I give my consent for
clinicians and staff at Leonardtown High School to arrange necessary emergency
treatments. Each participant must have had a physical checkup by a certified physician
within the past year. My son/daughter has had a physical within the last year and has been
declared healthy and able to participate in clinic activities.
I the undersigned, individually and as a parent and or guardian of
______________________, a minor, ask that he/she be admitted to participate in this
sports camp. I do hereby agree to release, discharge, and hold harmless Southern
Maryland Wrestling Club, St. Marys Wrestling Club, Leonardtown High School,
Leonardtown High School officers, agents and employees of and from all causes,
liabilities damages, claims, or demands whatsoever on account of any injury or accident
involving said minor arising out of minors attendance and participation at this sports
camp.
Signature: _____________________________

Date: ______________________

Cost: $150 ($50 non-refundable deposit due at time of registration, balance due 1st day of camp)
Please make checks payable: St. Marys Wrestling