Home of the Cobra All-Stars - (Happy Valley, OR)

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VISTORS COBRA WORKOUTS

* DATE ATTENDING:

* WORK OUT LOCATION:

* WRESTLER'S FIRST NAME:

* WRESTLER'S LAST NAME:

* AGE:

* WEIGHT:

* WRESTER'S CLUB/SCHOOL TEAM:

USA Wrestling Card No #:

* PARENT OR GUARDIAN NAME:

* Phone Number: for example 503-123-4567:

* EMAIL ADDRESS:

* Street Address:

* City:

* State:

* Zip Code:

Medical Insurance:

Group/Policy #:

I understand that wrestling is a strenuous activity and a physical is recommended before starting classes/wrestling camp or practices. I accept full responsibility for my child’s health and well-being, including Corona Virus/Covid19 in the voluntary exercise of cobra wrestling systems, llc.

I authorize cobra wrestling systems llc., to secure the services of a physician or hospital in the event of injury or sickness if a parent or guardian is not available. Wrestler (if a minor, parent or legal guardian) agrees to provide payment of any and all expenses for such necessary services. If the wrestler is a minor, their parent or legal guardian signature on the injury release form also binds them to this agreement.

I, on behalf of heirs, my assigns, and myself hereby acknowledge that Cobra Wrestling Systems LLC., Cobra affiliates, affiliated school districts, US Army shall not be liable for any claims of injury or sickness, Corona Virus/Covid19, or damages whatsoever to my child’s person or property arising out of or connected with the use of Cobra Wrestling Systems LLC, Marc Sprague, Alfa Sprague and others. I agree to indemnify and to hold harmless Cobra Wrestling Systems, USA wrestling, US Army, affiliated school districts, staff, volunteers, High School coaches, assistant coaches and Andrew and Christa DesRouchers from all claims by or liability to me.

I also acknowledge that my son / daughter may need transportation to and from camp as well as to and from host home or motels. I here by agree to indemnify and to hold all parties here in (drivers, host homes, parents, volunteers, all parties) regarding transportation and lodging, from all claims by or liability to me including my sons / daughters camp and travel team behavior.

Electronic signature, I am the legal guardian to the participant and by checking the box I agree to Cobra Wrestling Systems Registration and Waiver. *

VISA CARD NUMBER (or call 503-956-7022):

VISA 3-digit PIN NUMBER (or call 503-956-7022):

VISA CARD HOLDERS NAME (as it appears on the card):

VISA EXPIRATION DATE:

VISA CARDHOLDERS ZIP CODE:

VISA AMOUNT CHARGED $:

PLEASE CALL WITH ANY QUESTIONS.
COACH SPRAGUE
503-956-7022

* indicates required fields