STEPS TO REGISTRATION

Wrestler’s Name __________________________________________________________________

Date of Birth (m/d/yr) __________________________    Age ______    Grade _____

Years of wrestling experience: ____________________________________________

Wrestling awards: _________________________________________________________________

Parent / Guardian Name(s) _______________________________________________
Relationship _______________________

Address _______________________________________    City ____________________________
State ___________    Zip ____________

Home Phone_______________________    Work Phone _______________________
Cell# _____________________________

Parent e-mail_______________________    Wrestler e-mail_____________________

Please initial if it is ok to list the above information on
MATPAC Wrestling Roster____________

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The following information will be kept confidential.

Insurance Company___________________________________    Policy No.__________________

Family Doctor________________________________________    Phone No.__________________ Hospital____________________________

Please indicate another person to call if an accident occurs and we are unable to reach you:

Name: _____________________________________________    Phone No. __________________

The wrestler listed above has been granted permission to participate in wrestling activities as sanctioned by USA Wrestling and the MATPAC Wrestling Club. The wrestler has received a physical examination and is fit to participate.

Parent/Guardian Signature ____________________________    Date Signed _________________

Please read the alternative statements below and sign under the one that you choose. Sign only one!

1. If my child needs medical attention, it is my wish that I be 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.

Parent/GuardianSignature_____________________________    DateSigned __________________

2. If my child needs medical treatment while participating, it is my wish that the treatment be started while efforts are being made to contact me. So that treatment is not delayed, I consent to any medical procedures that the physician believes are needed, on the understanding that efforts to contact me will continue to be made. I accept responsibility for all costs related to such treatment.

Parent/GuardianSignature_____________________________    DateSigned __________________

MEDICAL HISTORY QUESTIONNAIRE
PLEASE PRINT IN CAPITAL LETTERS

Wrestler’s Name: ___________________________________
Date of Birth: ________________

PLEASE CIRCLE THE CORRECT ANSWER. ALL INFORMATION WILL BE CONFIDENTIAL.

YES/NO 1. Are you allergic to any general medication (aspirin, sulfa, penicillin, etc.)? If so please indicate what medication(s)

YES/NO 2. Are you now on any prescribed medication on a permanent or semi-permanentbasis? If so, please indicate the name of the medication and why it was prescribed

YES/NO 3. Have you ever had an epileptic seizure or been informed that you might have epilepsy?

YES/NO 4. Have you ever been treated for diabetes? If so, please indicate the type(s) of insulin or pills you use.

YES/NO 5. Has a medical doctor ever told you that you were anemic or had sickle cell anemia?

YES/NO 6. Do you have or have you ever had high blood pressure? If so, list any medication for it that you takeregularly

YES/NO 7. Do you have or have you ever had any of the following diseases? If so, please circle the appropriateones. Heart disease (rheumatic fever) Liver disease (hepatitis) Kidney disease (infections) Lung disease (pneumonia)

YES/NO 8. Have you ever been informed by a medical doctor that you have asthma? If so, what medications, if any, do you take regularly

YES/NO 9. Do you presently have an unrepaired hernia?

YES/NO 10. Have you ever been “knocked out” or experienced a concussion during the past 3 years? If so, give the dates of each

YES/NO 11. If the answer to No 10 is “yes” did the attending physician have you stay overnight in a hospital? If yes, give the dates of each

YES/NO 12. Have you ever had an injury to your neck involving nerves, vertebrae (bones), or discs that incapacitated you for a week or longer? If yes, give the dates of each such injury.

YES/NO 13. Do you wear any dental appliance? If yes, circle the appropriate appliance: Permanent bridge Permanent crown or jacket Braces Full plate Removable partial plate Permanent retainer Removable retainer

YES/NO 14. Do you wear contact lenses during competition?

YES/NO 15. Have you had a fracture during the past 2 years? If yes, indicate which bone was broken and the date if happened

YES/NO 16. Have you had a shoulder dislocation, separation or other shoulder injury in the past 2 years that incapacitated you for a week or longer? If so, give the date of the injury.

YES/NO 17. Have you ever had surgery to correct a shoulder condition? If so, give the dates and what was done.

YES/NO 18. Have you ever had an injury to your back?

YES/NO 19. Do you experience Pain in your back? If yes, indicate frequency:Seldom– Occasionally– Frequently - With vigorous exercise - With heavy lifting

YES/NO 20. Have you injured your knee during the past 2 years with severe swelling as a result?

YES/NO 21. Have you ever been told that you injured the ligaments and / or cartilage of either knee?

YES/NO 22. Have you ever been advised to have surgery to correct a knee problem?

YES/NO 23. If the answer to No. 22 is yes, has the surgery been completed? Date

YES/NO 24. Have you experienced a severe sprain of either ankle during the past 2 years?

YES/NO 25. Have you had any injury to your foot or toes in the past 2 years? If yes, explain:

YES/NO 26. Do you have any chronic conditions that have not been mentioned above? If so, explain:

The questions on both sides of this form have been answered completely and truthfully to the best of my knowledge.

Wrestler’s Signature _________________________________    Date________________________

Parent/ Guardian Signature____________________________    Date________________________

Waiver and Release from Liability

1. I, _______________________________, the undersigned, on behalf of myself, my heirs and next of kin, personal representative, agents, insurers, successors and assigns (all hereinafter “Releasers”) hereby FOREVER RELEASE, DISCHARGE AND COVENANT NOT TO SUE THE MATPAC WRESTILING Club, its insurers, its affiliated clubs, administrators, agents, directors, officers, state organizations, members, committees, volunteers, all employees of MATPAC Wrestling, and any and all participants, officials, referees, coaches, host clubs, sponsoring agencies, sponsors, advertisers, local organizing committees (and if applicable) owners, lessors and operators of premises used to conduct any MATPAC Wrestling sanctioned event, meet, practice or activity (all hereinafter “Releases”) from any and all liabilities,
claims, demands, causes of action or losses of any kind or nature, past, present or future, direct or consequential that I may hereafter have for PERSONAL INJURY, PERMANENT, TEMPORARY, TOTAL OR PARTIAL DISABILITY, DISFIGUREMENT, PARALYSIS AND ANY OTHER LOSSES OR DAMAGES TO PERSON OR PROPERTY OR DEATH, arising out of my participation in, attendance at or traveling to and from any MATPAC Wrestling sanctioned event or activity including, but not limited to, LOSSES CAUSED BY THE PASSIVE OR ACTIVE NEGLIGENCE OF THE RELEASEES, or hidden, latent or obvious defects in the facilities or equipment used.

2. Releaser understands and acknowledges that MATPAC Wrestling sanctioned activities and the sport of wrestling in general have inherent dangers that no amount of care, caution, training, instruction, supervision or expertise can eliminate. RELEASOR EXPRESSLY AND VOLUNTARILY ASSUMES ALL RISK OF PERSONAL INJURY, PERMANENT, TEMPORARY, TOTAL OR PARTIAL DISABILITY, DISFIGUREMENT, PARALYSIS AND ANY OTHER LOSSES OR DAMAGES TO PERSON OR PROPERTY OR DEATH, sustained while participating in, attending, preparing for or traveling to and from any MATPAC Wrestling sanctioned event, meet, practice or activity, including the risk of PASSIVE OR ACTIVE NEGLIGENCE OF THE RELEASEES, or hidden, latent or obvious defects in the facilities or equipment used.

3. Releaser acknowledges and fully understands that each participant in any MATPAC Wrestling sanctioned event, meet, practice or activity, including Releaser, will be engaging in activities that involve risk of serious injury, including permanent, temporary, total or partial disability, disfigurement, paralysis and any other losses to person or property, including death, and that severe social and economic losses may result not only from releaser’s own action, inactions or negligence, but also from the actions, inactions or negligence of other notwithstanding the rules of play or the condition of the premises or of any equipment used. Further Releaser acknowledges and fully understands that there may be other associated risks with such activities that are not known, or not reasonably foreseeable at this time.

4. Releasor understands that they are responsible for their child’s transportation to and from MATPAC Wrestling Club sanctioned events or activities, which include meets, duals, tournaments and practices.

I ACKNOWLEDGE THAT I HAVE HAD SUFFICIENT OPPORTUNITY TO REVIEW THE PROVISIONS OF THIS DOCUMENT AND UNDERSTAND ITS PURPOSE, MEANING AND INTENT.

(Participant’s Signature)_______________________________    (Date) ______________________
(Print Name)________________________

The undersigned, __________________ does hereby represent that he/she is, in fact, the parent or legal guardian of and acting in such capacity agrees to the terms and conditions of the above stated waiver and release.

(Signature of parent or legal guardian)_________________________________ (date)___________

(Print Name)______________________________________________________________________

(Relationship to minor)______________________________________________________________

USA Wrestling Membership ID:_______________________________________________________

* This yearly memebship is mandatory for participation with MATPAC Wrestling.  If you do not have a current USA Wrestling memebership, please register here.  Memberships are valid from September 1st through August 31 st of each year, please add or renew memberships under Club: MATPAC Wrestling and State: Colorado.

Please select one:
SEASON:      Fall_____Winter_____Spring______Summer_____
AGE:           High School_____Youth_____