GWC Wrestler Registration

WRESTLER INFORMATION

First Name:*

Last Name:*

Birthdate:*

Gender:*

Male

Female

Clear Current Selection

Email:*

Address 1:*

City:*

State:*

Zip:*

PARENT AND GUARDIAN INFORMATION

Parent/Guardian First Name:*

Parent/Guardian Last Name:*

Parent/Guardian Phone Number:*

Parent/Guardian Email:*

Parent/Guardian 2 First Name:

Parent/Guardian 2 Last Name:

Parent/Guardian 2 Phone:

Parent/Guardian 2 Email:

ADDITIONAL WRESTLER INFORMATION

Years of Wrestling Experience:*

Shirt Size:*

Shirt included w/membership fee

Grade:*

School:*

EMERGENCY CONTACT

Emergency Contact First Name:*

Emergency Contact Last Name:*

Emergency Contact Phone Number:*

Emergency Contact Relationship to Participant:*

MEDICAL INFORMATION

Medical Insurance Company:*

Medical Insurance Group Number:*

Medical Insurance Policy Number:*

Medical Insurance Policy Holder:*

Physician or Clinic Name:

Physician or Clinic Phone:*

Does this participant have any medical conditions, health concerns, allergies or special needs that we should be aware of?::*

Yes

No

Clear Current Selection

Please specify medical conditions, allergies, or other conditions:*

Electronic Signature:*

If my child needs medical attention, it is my wish that I am contacted before any medical procedures are taken on my child, unless immediate treatment is necessary to save my child’s life or to prevent permanent injury

If my child needs medical attention, it is my wish that the treatment is started while efforts are being made to contact me. So that treatment is not delayed, I consent to any medical procedures that the physical believes are needed and to contact me

Clear Current Selection

Website and Facebook Page Consent

Electronic Signature:*

Yes, you have my permission to post pictures of my son/daughter on the club website/Facebook page.

No, you do not have permission to post pictures of my son/daughter on the club website/Facebook page.

Clear Current Selection

Payment Options

PAY ON SITE: Submit total fees in person at any one of our practices and GWC sign up days via Visa, MasterCard, Discover, or checking account. (Cash will also be accepted)

SportsEngine Registration: Gering Wrestling Club

2016-2017 GWC Season Registration

WRESTLER INFORMATION

PARENT AND GUARDIAN INFORMATION

ADDITIONAL WRESTLER INFORMATION

EMERGENCY CONTACT

MEDICAL INFORMATION

Website and Facebook Page Consent

Payment Options