KIWC - Parent's Instructions on Medical Treatment
Wrestler's Name *
Your answer
Wrestler's Date of Birth *
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Parent/Guardian Name *
Your answer
Relationship *
Your answer
Address *
Your answer
Home Phone *
Your answer
Work Phone *
Your answer
Emergency Name *
Please indicate another person to call if an accident occurs and we are unable to reach you:
Your answer
Emergency Phone Number *
Your answer
Insurance Company *
Your answer
Policy Number *
Your answer
Family Doctor *
Your answer
Family Doctor Phone Number *
Your answer
Is your child presently on medication? *
If yes, please list the medication(s):
Your answer
Drug Sensitivities
Your answer
Other Allergies
Your answer
Date of your child's last complete physical examination by a medical doctor *
If this is more than one year ago, you must complete the medical history questionnaire - THIS WILL BE THE NEXT LINK WHEN YOU RETURN TO THE KIWC WEBSITE
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DD
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Please read the alternative statements below and select the one that you choose. *
Parent/Guardian Signature *
This constitutes a legal signature for your medical treatment selection.
Your answer
Date of Parent/Guardian Signature *
This constitutes a legal signature of your medical treatment instructions.
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DD
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YYYY
Wrestler's USA Wrestling Card Number *
Obtained from the USA Wrestling Membership website.
Your answer
Name of Club *
Your answer
Coach's Name
Your answer
Coach's Phone Number
Your answer
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