Carlstadt / East Rutherford Jr Wrestling Application
Please Fill Out All Information for Each Wrestler
Wrestler's First Name *
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Wrestler's Last Name *
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Wrestler's Birthdate *
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How Many Year's Experience *
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Street Address *
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Town *
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Grade *
School *
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Parent Information
Following Questions are for Parent Contact Information
Parent or Legal Guardian's Name *
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Parent or Legal Guardian's Address *
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Parent or Legal Guardian's Cell Number *
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Parent or Legal Guardian's Email *
All Contact is Done Through Email
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Parent or Legal Guardian's Name
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Parent or Legal Guardian's Address
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Parent or Legal Guardian's Cell Number
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Parent or Legal Guardian's Email
All Contact is Done Through Email
Your answer
Parent/Guardian Permission, Medical Information, and Media Release Form
I/WE THE PARENT(S) OR LEGAL GUARDIAN(S) OF THE ABOVE NAMED CHILD, HEREBY GIVE MY/OUR APPROVAL TO THIS PARTICIPATION IN ANY OF THE CARLSTADT/EAST RUTHERFORD JR. WRESTLING DURING THE CURRENT SEASON. I/WE ASSUME ALL RISKS AND HAZARDS TO THE CONDUCT OF THE ACTIVITIES AND TRANSPORTATION TO AND FROM THE ACTIVITIES. I/WE DO FURTHER RELEASE, ABSOLVE, INDEMNIFY AND HOLD HARMLESS THE CARLSTADT/ EAST RUTHERFORD WRESTLING ORGANIZERS, SPONSORS, DIRECTORS, AND SUPERVISORS APPOINTED BY THEM. I/WE LIKEWISE WAIVE, TO THE EXTENT NOT COVERED BY LIABILITY INSURANCE, ANY CLAIM AGAINST ANY PERSON TRANSPORTING MY/OUR CHILD TO OR FROM THE ACTIVITIES. I/WE WILL FURNISH A CERTIFIED BIRTH CERTIFICATE OF THE ABOVE NAMED REGISTRANT UPON REQUEST OF THE PROGRAM OFFICIALS. *
I/WE, THE PARENT(S) OR LEGAL GUARDIAN OF ABOVE NAMED CHILD, A MINOR, DO HEREBY AUTHORIZE AND CONSENT TO AN X-RAY EXAMINATION, ANESTHETIC, MEDICAL OR SURGICAL DIAGNOSIS RENDERED UNDER THE GENERAL OR SPECIAL SUPERVISION OF ANY MEMBER OF THE MEDICAL STAFF AND EMERGENCY ROOM STAFF LICENSED UNDER THE PROVISIONS OF THE MEDICAL PRACTICE ACT OR A DENTIST LICENSED UNDER THE DENTAL PRACTICE ACT AND ON THE STAFF OF ANY GENERAL HOSPITAL HOLDING A CURRENT LICENSE TO OPERATE FROM THE STATE OF NEW JERSEY, DEPARTMENT OF PUBLIC HEALTH. IT IS UNDERSTOOD THAT THIS AUTHORIZATION IS GIVEN IN ADVANCE OF ANY SPECIFIC DIAGNOSIS, TREATMENT OR HOSPITAL CARE BEING REQUIRED, BUT GIVEN TO PROVIDE AUTHORITY AND POWER TO RENDER CARE WHICH IS THE AFOREMENTIONED PHYSICIAN, IN THE EXERCISE IN HIS/HER BEST JUDGEMENT, MAY DEEM ADVISABLE. IT IS UNDERSTOOD THAT EFFORTS SHALL BE MADE TO CONTACT THE UNDERSIGNED PRIOR TO RENDERING TREATMENT TO THE PATIENT, BUT THAT ANY OF THE ABOVE MENTIONED TREATMENTS WILL NOT BE WITHHELD IF THE UNDERSIGNED CANNOT BE REACHED. *
I/WE HEREBY AUTHORIZE THE PUBLICATION OF PHOTOGRAPHS TAKEN OF MYSELF AND/OR MY CHILD/CHILDREN AS WELL AS MINORS UNDER MY GUARDIANSHIP, AND OUR NAMES AND LIKENESSES, FOR USE IN PRINT, ONLINE, AND VIDEO-BASED MARKETING MATERIALS, AS WELL AS OTHER PUBLICATIONS. I/WE, THE PARENT(s) OR LEVAL GUARDIAN OF ABOVE NAMED CHILD, A MINOR, DO HEREBY RELEASE AND HOLD HARMLESS THE WILDCATS JR WRESTLING PROGRAM FROM ANY REASONABLE EXPECTATION OF PRIVACY OR CONFIDENTIALITY FOR MYSELF AND FOR THE MINOR CHILD AND/OR CHILDREN LISTED ABOVE. FURTHER, I ATTEST THAT I AM THE PARENT OR LEGAL GUARDIAN OF THE CHILD/CHILDREN LIST ABOVE AND THAT I HAVE FULL AUTHORITY TO CONSENT AND AUTHORIZE THE WILDCATS JR WRESTLING PROGRAM TO USE THEIR LIKENESSES AND NAMES. I FURTHER ACKNOWLEDGE THAT PARTICIPATION IS VOLUNTARY AND THAT NEITHER I/WE, THE MINOR CHILD, OR MINOR CHILDREN WILL RECEIVE FINANCIAL COMPENSATION OF ANY TYPE ASSOCIATED WITH THE TAKING OR PUBLICATION OF THIS MEDIA. I ACKNOWLEDGE AND AGREE THAT PUBLICATION OF SAID MEDIA CONFERS NO RIGHTS OF OWNERSHIP OR ROYALTIES WHATSOEVER. I HEREBY RELEASE THE WILDCATS JR WRESTLING PROGRAM, ITS CONTRACTORS, IT EMPLOYEES, AND ANY THIRD PARTIES INVOLVED IN THE CREATION OF PUBLICATIONS, FROM LIABILITY FOR ANY CLAIMS BY ME OR ANY THIRD PARTY IN CONNECTION WITH MY PARTICIPATION OR THE PARTICIPATION OF THE MINOR CHILD/CHILDREN LISTED ABOVE. *
Parent or Legal Guardian Signature *
By Typing your Name you are Legally Signing this Document
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Date *
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