Dragon Wrestling Youth Registration Form

$25.00 Registration Fee per wrestler

_____________________________________________________ Birth Date ________________ Age ______
Participants Name (First and Last)

______________________________________________________________________ Approx. Weight ______

Address
City
State
Zip Code
_____________________________________________________
Mothers Name (First and Last)

Home Phone ____________________ Work Phone ____________________ e-mail ______________________

_____________________________________________________
Fathers Name (First and Last)

Home Phone ____________________ Work Phone ____________________ e-mail ______________________

How did you hear about this program?
_____ Flyer from school
_____ Dragon Wrestling Webpage
_____ A Friend
_____ Other ________________________
T-Shirt Size
(Check Appropriate Size)

Youth Size

Shorts Size
(Check Appropriate Size)
Youth Size

YS- _____

YS- _____

YM- _____

YL- _____

YM- _____

YL- _____

PARENT RELEASE OF LIABILITY

In consideration of my childs participation in Dragon Youth Wrestling, I hereby, for myself, my child my
spouse, heirs, successors and assigns, waive and release any and all claims against the Dragon Youth Wrestling
program and its volunteers, agents, or employees, for any and all injuries or other damage arising out of or
connected to with participation in Dragon Youth Wrestling. I agree and consent to emergency treatment of
my child by a physician or hospital in the event that I (or my spouse) cannot be reached.
________________________________________________
Parent or Guardian's Signature

_____________________
Date

To be completed by program associate: $25 Paid _____ Yes _____ No

_____ Cash _____ Check# ________ Indicate check #

PARENTS INSTRUCTIONS ON MEDICAL TREATMENT

PLEASE PRINT IN ALL CAPITAL LETTERS
Wrestlers Name _______________________________________________ Date of Birth ________________

Please indicate another person to call if an accident occurs and we are unable to reach you:
EMERGENCY CONTACT #1
Name of Contact _______________________________________________ Relationship _________________
Home Phone ____________________________

Cell Phone _____________________________

EMERGENCY CONTACT #2 (if available)

Name of Contact _______________________________________________ Relationship _________________
Home Phone ____________________________

Cell Phone _____________________________

**Are there any allergies or medical conditions the coaches of Dragon Wrestling need to be aware of?**
If so please list them below:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please understand by providing the information above and signing below you are giving permission for
these people to be contacted in the event you cannot be reached. This will allow the above named
individual(s) to assist with contacting the parent/guardian, providing information about the child, or helping
in the event of an emergency.

________________________________________________
Parent or Guardian's Signature

_____________________
Date