Jr Patriots Wrestling Registration
Wrestler Information
What high school will you attend?
1st Wrestler's First Name
Your answer
1st Wrestler's Last Name
Your answer
1st Wrestler's Date of Birth
MM
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DD
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YYYY
1st Wrestler's Grade
2nd Wrestler's First Name
Your answer
2nd Wrestler's Last Name
Your answer
2nd Wrestler's Date of Birth
MM
/
DD
/
YYYY
2nd Wrestler's Grade
3rd Wrestler's First Name
Your answer
3rd Wrestler's Last Name
Your answer
3rd Wrestler's Date of Birth
MM
/
DD
/
YYYY
3rd Wrestler's Grade
Parent/Guardian Information
Primary Guardian First Name
Your answer
Primary Guardian Last Name
Your answer
Relationship to Wrestler
Cell Phone
Your answer
Home Phone
Your answer
Email Address
Your answer
Primary Guardian Street Address
Your answer
Primary Guardian City
Your answer
Primary Guardian State
Your answer
Primary Guardian Zip Code
Your answer
Guardian 2 First Name
Your answer
Guardian 2 Last Name
Your answer
Relationship to Wrestler
Guardian 2 Cell Phone
Your answer
Guardian 2 Home Phone
Your answer
Guardian 2 Email Address
Your answer
Emergency Contact Information
Emergency Contact 1 Full Name
Your answer
Emergency Contact 1 Cell Phone
Your answer
Emergency Contact 1 Home/Other Phone
Your answer
Relationship to Wrestler
Emergency Contact 2 Full Name
Your answer
Emergency Contact 2 Cell Phone
Your answer
Emergency Contact 2 Home/Other Phone
Your answer
Relationship to Wrestler
Medical Information
Physician Name
Your answer
Physician Phone Number
Your answer
Preferred Hospital
Your answer
Parent/Guardian Consent
IN CONSIDERATION OF YOUR ACCEPTANCE INTO THIS PROGRAM, I, INTENDING TO BE LEGALLY BOUND HEREBY, FOR MYSELF, MY HEIRS, EXECUTORS AND ADMINISTRATORS, WAIVE AND RELEASE THE PARKWAY SCHOOL DISTRICT AND PARKWAY SOUTH JR. PATRIOT WRESTLING PROGRAM, THEIR COACHES, REPRESENTATIVES, COMMITTEES, AND MEMBERS FROM ANY AND ALL CLAIMS OR RIGHTS TO DAMAGE FOR INJURIES OR LOSSES SUFFERED BY ME DIRECTLY OR INDIRECTLY IN TRAINING, OR TRAVELING TO OR FROM, OR COMPETING IN, OR ATTENDING THE PARKWAY SOUTH JR. PATRIOT WRESTLING PROGRAM. ALL THE INFORMATION GIVEN IS TRUE AND ANYONE FALSIFYING INFORMATION WILL BE DROPPED FROM THIS PROGRAM. AS THE PARENT OR LEGAL GUARDIAN, I GIVE MY CONSENT FOR EMERGENCY MEDICAL CARE PRESCRIBED BY A DOCTOR OF MEDICINE.

IT IS THE SOLE RESPONSIBILITY OF THE PARENTS TO PURCHASE WRESTLING SHOES AND HEADGEAR. YOU WILL BE NOTIFIED OF ALL TOURNAMENTS IN ADVANCE. ANY AND ALL TOURNAMENTS ARE AT YOUR DISCRETION.

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