DATE:

NAME:

ADDRESS:
|
CSZ:

BIRTH DATE:     AGE     GRADE     
 

SCHOOL:

YEARS OF WRESTLING EXPERIENCE: NEW 1 2 3 4 5 6 7

MOTHER:          HOME PHONE:
WORK PHONE:                CELL PHONE:
MOTHER EMAIL:

FATHER:             HOME PHONE:
WORK PHONE:                CELL PHONE:
FATHER EMAIL:

SHIRT SIZE:  YS YM YL AS AM AL AXL    

SHORT SIZE:  YS YM YL AS AM AL AXL  

PERSON TO NOTIFY IN CASE OF EMERGENCY:

RELATIONSHIP:

ADDRESS:

HOME PHONE:    CELL PHONE:

FAMILY PHYSICIAN:

PHYSICIAN PHONE:
 

FAMILY DENTIST:

DENTIST PHONE:
 

ALLERGIES, MEDICATIONS BEING TAKEN, PHYSICAL IMPAIRMENTS, OR PERSONAL INFORMATION, ETC. OF WHICH PHYSICIAN SHOULD KNOW.


 

Don't forget to return to the main application page and print the waiver form!


By clicking on the Submit button I verify that the above information is accurate to the best of y knowledge. My electronic signature indicates approval for my child to participate in Boardman Youth Wrestling.

ELECTRONIC SIGNATURE:
(Type Name)