REGISTRATION – Shelton Wrestling

CHILDS LEGAL NAME(Required)

First Last

CHILDS SCHOOL(Required)

CHILDS GRADE(Required)

CHILDS DATE OF BIRTH(Required)

AGE (BY DEC 31)(Required)

WEIGHT(Required)

USAW MEMBER #(Required)

Choose a SHIRT SIZE(Required)

PARENT/LEGAL GUARDIAN MAILING ADDRESS(Required)

Street Address Address Line 2 City State ZIP Code

PARENT/LEGAL GUARDIAN #1(Required)

PARENT/LEGAL GUARDIAN #1 PHONE(Required)

PARENT/LEGAL GUARDIAN #1 EMAIL

Enter Email Confirm Email

PARENT/LEGAL GUARDIAN #2

PARENT/LEGAL GUARDIAN #2 PHONE

PARENT/LEGAL GUARDIAN #2 EMAIL

Enter Email Confirm Email

EMERGENCY CONTACT #1(Required)

INCASE PARENT / GUARDIAN CAN NOT BE REACHED

First Last

EMERGENCY CONTACT’S RELATIONSHIP TO PLAYER(Required)

FRIEND / AUNT / UNCLE / TEACHER / ETC

EMERGENCY CONTACT #2

INCASE PARENT / GUARDIAN CAN NOT BE REACHED

First Last

EMERGENCY CONTACT’S RELATIONSHIP TO PLAYER

FRIEND / AUNT / UNCLE / TEACHER / ETC

HAS CHILD PREVIOUSLY PARTICIPATED IN WRESTLING BEFORE?(Required)

YES, CHILD HAS PREVIOUSLY PARTICIPATED IN WRESTLING

NO, CHILD HAS NOT PREVIOUSLY PARTICIPATED IN WRESTLING

WHERE HAS THE CHILD PREVIOUSLY PARTICIPATED IN WRESTLING?(Required)

DOES YOUR CHILD HAVE ANY MEDICAL, ALLERGIC, OR BEHAVIORAL ISSUES?(Required)

YES, CHILD DOES HAVE MEDICAL, ALLERGIC, OR BEHAVIORAL ISSUES?

NO, CHILD DOES NOT HAVE ANY MEDICAL, ALLERGIC, OR BEHAVIORAL ISSUES?

PLEASE EXPLAIN YOUR CHILDS MEDICAL, ALLERGIC, OR BEHAVIORAL ISSUES?(Required)

PHYSICIAN'S NAME

PHYSICIAN'S OFFICE NUMBER

YOUR INSURANCE COMPANY

ID/POLICY #

DO YOU NEED FINANCIAL ASSISTANCE ?(Required)

YES, WE NEED FINANCIAL ASSISTANCE

NO, WE DO NOT NEED FINANCIAL ASSISTANCE

HOW MUCH CAN YOU AFFORD NOW ?

REGISTRATION - PAYMENT UNDERSTANDING

Parent / Legal Guardian Signature(Required)

I UNDERSTAND THAT MY REGISTRATION IS NOT COMPLETE UNTIL THE REGISTRATION FEE HAS BEEN PAID IN FULL AND A COPY OF MY ATHLETES BIRTH CERTIFICATE HAS BEEN RECEIVED.

CONSENT TO MEDICAL CARE AND TREATMENT

ALL CHILDREN REGISTERED WITH THE SHELTON WRESTLING CLUB WILL BE INSURED BY A SECONDARY CARRIER PROVIDED BY USAWRESTLING, EFFECTIVE AFTER PARENT/GUARDIAN INSURANCE HAS BEEN EXHAUSTED. THERE IS A DEDUCTIBLE ON THE USAW INSURANCE. SHELTON WRESTLING CLUB RECOMMENDS A PHYSICAL EXAMINATION FOR YOUR CHILD PRIOR TO PARTICIPATION.

Parent / Legal Guardian Signature(Required)

I, (PARENT/GUARDIAN NAME LISTED ABOVE) AUTHORIZE ALL MEDICAL AND SURGICAL TREATMENT, X-RAY, LABORATORY, ANESTHESIA AND OTHER MEDICAL HOSPITAL PROCEDURES AS MAY BE PERFORMED OR PRESCRIBED BY A LICENSED PHYSICIAN AND FACILITIES FOR (CHILD’S NAME LISTED ABOVE). IT IS EXPECTED 1 PARENT/GUARDIAN STAYS AT PRACTICE. IF PARENT IS NOT AVAILABLE YOU AUTHORIZE FOR MEDICAL RELEASE.

HOLD HARMLESS AGREEMENT

WRESTLING IS A VIGOROUS ACTIVITY AND THE POSSIBILITY OF INJURY DOES EXIST.

Parent / Legal Guardian Signature(Required)

I GIVE APPROVAL AND PERMISSION FOR MY CHILD TO PARTICIPATE IN THE SHELTON WRESTLING ASSOCIATION. I HEREBY WAIVE ALL CLAIMS AND LEGAL ACTION, FINANCIAL OR OTHERWISE, AGAINST THE ABOVE JUNIOR WRESTLING CLUB, IT’S ELECTED AND APPOINTED OFFICIALS, OR ANY VOLUNTEER CONNECTED WITH THE PROGRAM FOR INJURIES WHICH MIGHT OCCUR DURING PRACTICE, TRAVEL OR GAME COMPETITION.

PAYMENT / FINANCIAL SECTION

HOW DO YOU WANT TO PROCEED ?(Required)

CHOOSE A PAYMENT PATH

I want to pay ONLINE NOW

I want to register, but need FINANCIAL ASSISTANCE

Consent For Invoice(Required)

I agree to be billed / invoiced for the registration fee.

I consent to being invoiced for up to $80 registration fee depending on the information provided above in my registration form. I understand that my registration fee must be paid or arrangements for payment are required prior to my child wrestling or attending practice unless otherwise pre-approved.

Confirm Contact Name For Financial Assistance(Required)

First Last

Confirm Contact Phone For Financial Assitance(Required)

Confirm Contact Email For Financial Assistance

Enter Email Confirm Email

Registration Fee(Required)

PLEASE CHOOSE FROM ONE OF THE OPTIONS BELOW. IF YOU CHOOSE USA CARD HOLDER, PLEASE BRING YOUR CARD TO NEXT MEETING OR MATCH. FINANCIAL ASSISTANCE IS AVAILABLE, PLEASE CHOOSE THIS OPTION IF YOU ARE NEEDING A LITTLE ASSISTNCE.

GENERAL - REGISTRATION FEE $80

Hidden

GENERAL REGISTRATION - PAYMENT OPTIONS - PLEASE CHOOSE(Required)

PAY IN FULL TODAY

GENERAL REGISTRATION - PAYMENT PLAN - 1/4 FEE COLLECTED TODAY

Total

Billing First Name(Required)

Billing Last Name(Required)

Billing Address For Payment Form(Required)

Street Address Address Line 2 City State ZIP Code

Contact Phone For Billing Issues(Required)

Email for Billing Payment Notices(Required)

Registration and Release (Online)

REGISTRATION - PAYMENT UNDERSTANDING

CONSENT TO MEDICAL CARE AND TREATMENT

HOLD HARMLESS AGREEMENT

PAYMENT / FINANCIAL SECTION