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Jr Patriots Wrestling Registration
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Email *
Wrestler Information
What high school will you attend? *
1st Wrestler's First Name *
1st Wrestler's Last Name *
1st Wrestler's Date of Birth *
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1st Wrestler's Grade *
2nd Wrestler's First Name
2nd Wrestler's Last Name
2nd Wrestler's Date of Birth
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YYYY
2nd Wrestler's Grade
3rd Wrestler's First Name
3rd Wrestler's Last Name
3rd Wrestler's Date of Birth
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/
DD
/
YYYY
3rd Wrestler's Grade
Parent/Guardian Information
Primary Guardian First Name *
Primary Guardian Last Name *
Relationship to Wrestler *
Cell Phone *
Home Phone
Email Address *
Primary Guardian Street Address *
Primary Guardian City *
Primary Guardian State *
Primary Guardian Zip Code *
Guardian 2 First Name *
Guardian 2 Last Name *
Relationship to Wrestler *
Guardian 2 Cell Phone *
Guardian 2 Home Phone
Guardian 2 Email Address *
Emergency Contact Information
Emergency Contact 1 Full Name *
Emergency Contact 1 Cell Phone *
Emergency Contact 1 Home/Other Phone
Relationship to Wrestler *
Emergency Contact 2 Full Name
Emergency Contact 2 Cell Phone
Emergency Contact 2 Home/Other Phone
Relationship to Wrestler
Medical Information
Physician Name
Physician Phone Number
Preferred Hospital
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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