2022 PAUSAW - Medical Waiver Form [All Teams]
This must be filled out  by all wrestlers attending any of the National Duals and/or Fargo.

Only one form needs to be completed per wrestler as long as all events are checked appropriately. This form must be completed prior to checking in.
Sign in to Google to save your progress. Learn more
Wrestler's Name *
Wrestler's USAW ID # *
What Team(s) are you on? *
MEDICAL CONSENT INFORMATION                           Name of Primary Insurance Company *
Policy Number *
Insurance Company Phone Number *
Family Doctor *
Family Doctor's Phone Number *
Presently on any medication *
If Yes (please describe)
Drug Sensitivities or Allergies *
Special Medical Conditions  
Please indicate another person to call in case of emergency (Please Name and Phone Number) *
Parent or Guardian of minor must read and complete the following:      Without this signed authorization from the parent/guardian, hospitals in many states are obligated by law to delay treatment of a contestant’s injury or illness until the parents can be reached by telephone and their permission granted to begin treatment. Such a delay can prove unnecessarily painful and even dangerous to the athlete, particularly if the parents cannot be reached immediately. To avoid such delays, the parent/guardian should check one of the options *
CONSENT AND RELEASE FORM                                           In consideration for the opportunity to participate at a USA Wrestling Sanctioned and/or Official Championship Event (the “Event”), the undersigned and his/her parent or guardian, if applicable (“Participant”) hereby acknowledges that the “Event,” and related activities and performances, may be televised live and/or videotaped for broadcast, cable cast, home video entertainment and/or any other use or distribution (collectively, “Dissemination”) in a manner not inconsistent with applicable rules or The United States of America Wrestling Association, Inc., d/b/a USA Wrestling, Inc. (“USAW”) and/or United World Wrestling (“UWW”) and hereby consents that USAW, for purposes of US- AW’s athletics/sports programs and related events and activities, and any television network, production company or any other par- ties with which USAW has agreements for such purposes, and/   or their licensees, shall have the right, without any compensation to participant, to use Participant’s name, photograph, image, like- ness, biography and accomplishments and displays of wrestling ability in any Dissemination of the Event and for the purpose of advertising, promoting and publicizing the events and activities of USAW and the program and/or any program series of which any Dissemination of the Event is a part (provided that none of the above shall be used in such fashion so as to constitute an endorsement of any commercial  product).  Participant  agrees, for and on behalf of Participant and Participant’s heirs, personal representatives, administrators, agents, successors and assigns, to release, indemnify and hold harmless USAW and its officers,directors, agents, employees and licensees from any claim of any nature based upon or arising out of any Dissemination or other permitted uses contemplated by this Consent and Release *
ASSUMPTION OF RISK, CODE OF CONDUCT & RELEASE OF LIABILITY WAIVER IN CONSIDERATION FOR the opportunity to participate in the EVENT  (I have read the information and agreed to all the individual terms as stated *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy