Kid Eagles Wrestling Club

Medical Information and Waiver Form + (ALL)

Below are a series of forms. These forms are required for all wrestlers. Please fill them out completely AFTER you have read the Concussion Awareness form on the "Handouts" tab of the web page or you have completed the free on-line AFHS concussion class linked to this website.

WRESTLER INFORMATION

* First Name:

* Last Name:

* Birthdate:

* Gender:

PARENT/GUARDIAN #1

* Firstname:

* Lastname:

I/we have read the Concussion Awareness form and/or completed the free AFHS Concussion Awareness course on-line. *

MEDICAL/EMERGENCY CONTACT INFORMATION

* Emergency Contact Name:

* Phone:

* Relationship to Wrestler:

Family Doctor:

Please list all medications your wrestler currently uses:

Family Doctor Phone Number:

Date of your wrestler's last physical examination:

Please list any allergies your wrestler has (medicince, food, etc):

Insurance Carrier:

Policy #:

Please read the two statements below. Select the box above the selection that you choose as it relates to medical treatment for your wrestler while attempts are being made to contact you. Please select ONLY ONE of the two boxes below.

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 costs related to such treatment.

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.

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT WITH PARENTAL CONSENT.

In consideration of being permitted to participate in any way in any event ("Activity") at any time during the length of the scheduled season and post season, I/ my minor son or daughter, for myself, my personal representatives, assigns, heirs, and next of kin:
1. ACKNOWLEDGE, agree, and represent that I understand the nature of the Activity and that I/ my son or daughter, is qualified, in good health, and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time I believe the conditions to be unsafe, I will immediately discontinue further participation in the Activity.
2. FULLY UNDERSTAND that: a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS, AND DEATH ("Risks"); b) these Risks and dangers may be caused by my/ my son or daughter's own actions or inactions of others participating in the Activity, the conditions in which the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES NAMED BELOW; c) there may be OTHER RISKS or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my/ my son or daughter's participation in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel, sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be considered one of the "Releasees" herein) FROM ALL LIABILITY CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON MY/ MY SON OR DAUGHTER’S ACCOUNT CAUSED OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTEHR AGREE that if, despite the RELEASE AND WAIVER OF LIABLITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or anyone on my/ my son or daughter’s behalf, makes a claim against any of the Releasees, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss, liability, damage, or cost which may be incurred as a result of such claim.
I ACKNOWLEDGE THAT I AM THE PARENT OR LEGAL GUARDIAN OF THE MINOR CHILD LISTED ON THIS FORM AND THAT I AM OVER 18 YEARS OF AGE. I FURTHER ACKNOWLEDGE THAT I AND MY SON OR DAUGHTER HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT WE HAVE GIVEN UP SUBSTANTIAL RIGHTS BY CHECKING THE BOX BELOW AND THAT WE HAVE CHECKED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID, THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
WE FURTHER ACKNOWLEDGE THAT IF WE SUBMIT THIS FORM ELECTRONICALLY, CHECKING THE BOX BELOW REPRESENTS OUR SIGNATURE AND ACCEPTANCE OF ALL TERMS.

I/we agree with the above *

Photo Release Permission

Photos and videos of our wrestlers will be taken throughout the season by various sources. We would like to be able to post them on our website and other publications, but will only do so with your permission. Please select the line below with your wishes regarding photos of your wrestler being displayed on any of our media forms.

If you have never wrestled with us before, please do not enter anything below this line.

USA Card Number:

Notes:

* indicates required fields

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Medical Information and Waiver Form + (ALL)