2016-17 FAYWC Registration
Fort Atkinson Youth Wrestling
NOTE:
This registration is only the "paperwork" portion - YOU WILL STILL NEED TO COME TO REGISTRATION NIGHT! It will be held on November 2 from 5:30 - 6:30 at Fort Atkinson High School. All fees associated with your wrestler will be paid at that time. There is also a short parent's meeting that you should attend from 6:15-6:45. Great things are in store for your program this year - plan on sticking around to hear about them!
Wrestler's Last Name
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Wrestler's First Name
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Wrestler's Grade
Required
Wrestler's Age
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School Attending
Required
T-Shirt Size
Required
Parent / Guardian Name(s)
Your answer
Parent / Guardian Address
Your answer
Parent / Guardian Phone (1)
Your answer
Parent / Guardian Phone (2)
Your answer
Parent / Guardian Email Address (1)
Your answer
Parent / Guardian Email Address (2)
Your answer
Alternate (Emergency) Adult Contact Name
Your answer
Alternate (Emergency) Adult Contact Phone
Your answer
PARENTAL RELEASE FROM LIABILITY AND REQUEST FOR EMERGENCY MEDICAL ADMINISTRATION

As a parent or guardian, I give my permission for the above named to participate in the Fort Atkinson Youth Wrestling Club for the 2016 / 2017 season. I hereby authorize my child to participate in wrestling activities and workout in said activities and hereby release and waive any claim, demand, cause, action, assertion or liability against the Fort Atkinson Youth Wrestling Club, its officers, coaches, chaperones, and the Fort Atkinson School District, which may result from any accidents or happenings occurring during or as a result of such activities. Further, if emergency medical administration is needed by my child during or resulting from the said activities, I authorize any of the chaperones or coaches to authorize any licensed physician or surgeon to administer said emergency medical attention. I further waive any claim, demand, cause, action or assertion of liability against administering emergency medical attention.
By typing in my name below, I hereby agree to the above parental release.
Your answer
Health Insurance
Below, please provide health insurance information. If you do not have insurance, please respond "n/a". All responses will be confidential.
Primary Insurance Company (name)
Your answer
Primary Insurance Group Number
Your answer
Primary Insurance Policy / Member ID number
Your answer
Primary Physician Name
Your answer
Primary Physician Phone Number
Your answer
Medical History
Please answer all questions below with regards to the above wrestler. Again, all responses will be kept confidential.
Any allergies to medication?
If you answered yes, please list any medication(s) he/she is allergic to.
Your answer
Is the above wrestler currently taking any medication?
If you answered yes, please list any medication(s) that he/she is currently taking.
Your answer
Are there any medical conditions that our coaching staff should be aware of with regards to the above wrestler?
If you answered yes, please list any applicable medical conditions.
Your answer
Parent and Athlete Concussion Information & Consent
A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussions are mild, all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. In other words, even a “ding” or a bump on the head can be serious. You can’t see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away.
Symptoms may include one or more of the following:
Headaches
“Pressure in head”
Nausea or vomiting
Neck pain
Balance problems or dizziness
Blurred, double, or fuzzy vision
Sensitivity to light or noise
Feeling sluggish or slowed down
Feeling foggy or groggy
Drowsiness
Change in sleep patterns
Amnesia
“Don’t feel right”
Fatigue or low energy
Sadness
Nervousness or anxiety
Irritability
More emotional
Confusion
Concentration or memory problems (forgetting game plays)
Repeating the same question/comment

Signs Observed by Teammates, parents & coaches include:
Appears dazed
Vacant facial expression
Confused about assignment
Forgets plays
Is unsure of game, score or opponent
Moves clumsily or displays in coordination
Answers questions slowly
Show behavior or personality changes
Can’t recall events prior to hit
Can’t recall events after hit
Seizures or convulsions
Any change in typical behavior or personality
Loses consciousness

What can happen if my child keeps playing with a concussion or returns too soon?
Athletes with the signs and symptoms of concussion should be removed from play immediately. Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is well known that adolescent or teenage athlete will often under report symptoms of injuries. And concussions are no different. As a result, education of administrators, coaches, parents and students is the key for student athlete’s safety.

If you think your child has had a concussion:

Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately. No athlete may return to activity after an apparent head injury or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. Close observation of the athlete should continue for several hours. The new “Zackery Lystedt Law” in Washington now requires the consistent and uniform implementation of long and well-established return to play concussion guidelines that have been recommended for several years:

“a youth athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from competition at that time”
And

“...may not return to play until the athlete is evaluated by a licensed heath care provider trained in the evaluation and management of concussion and received written clearance to return to play from that health care provider”.
You should also inform your child’s coach if you think that your child may have a concussion. Remember, it’s better to miss one game than miss the whole season. And when in doubt, the athlete sits out.

For current and up-to-date information on concussions you can go to:
http://www.cdc.gov/ConcussionInYouthSports/

By typing in my name below, I hereby acknowledge that I have read and am familiar with the concussion information above. I am also acknowledging that I have shared this information with my wrestler.
Your answer
Social Media Release
I hereby agree to allow Fort Atkinson Youth Wrestling to record and publish photos and videos (including audio) of the above named participant for the purpose of promoting Fort Atkinson Youth Wrestling and for documenting and/or reporting events and activities.

I understand photographs, video and/or audio recordings to be taken of the participant and/or family members at practice, during competition, recreational play, as well as other Fort Atkinson Youth Wrestling events. I understand that this media will be produced and used for promotional purposes, and I authorize Fort Atkinson Youth Wrestling to use said photographs, video and/or audio recording on its website and social media platforms, such as Facebook, Twitter, YouTube etc., as well as other official printed publications without further consideration.

In addition, I acknowledge Fort Atkinson Youth Wrestling to crop or treat the media at its discretion, and I also acknowledge that Fort Atkinson Youth Wrestling may chose not to use the participant / family member(s) image at this time, but may do so at its own discretion at a later date. I also understand that once the participant, or participants family member(s) image(s) have been captured, they me be posted on the Fort Atkinson Youth Wrestling website or social media platforms, the image can be downloaded by any computer user on or off the premises. Therefore, I agree to indemnify and hold harmless from any claims Fort Atkinson Youth Wrestling coaches, Fort Atkinson Youth Wrestling Board Members and other team members.

By typing in my name below, I hereby agree to the above Social Media Release.
Your answer
STAY IN TOUCH
www.fortwrestling.org (website)

forthyouthwrestling@gmail.com (email)

Please check the FAYWC website often. Important information regarding practices and upcoming events will be posted. We will also be sending information out via email, so please make sure you provide us with a correct email address.

Fort Atkinson Wrestling on Facebook
-This is the biggest source of information for FAYWC.

@FAWrestlingClub
Get Fort Wrestling text alerts via Twitter. You do NOT need to have a Twitter account to follow. Simply text
follow to 40404. (Standard text messaging rates do apply.)

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