Jackson Wrestling
     
 
Youth Online Registration
General Information:
Mailing Address
Street 1: *
Street 2:
City: *
State: * Ohio
ZIP Code: *
Primary Email Address
Email Address: *
Primary Phone
Phone Number: *
Contact Information:
Mother
First Name:
Last Name:
Email Address:
Home Phone:
Work Phone:
Cell Phone:
Father
First Name:
Last Name:
Email Address:
Home Phone:
Work Phone:
Cell Phone:
Emergency Contacts
Contact Name #1: *
Contact Phone #1:
Contact Name #2: *
Contact Phone #2:
I would be willing to assist in the following positions:
    
Emergency Information:
Insurance Information
Carrier Name: *
Policy Number: *
Doctor Information
Hospital of Choice: *
Participant Information:
Saved Participants:
No Participants have been Added. Click the Button Below to Add a Wrestler
Waivers and Acknowledgements:
NOTICE!  Prior to submitting this form, you must read the following waivers and acknowledgements. Check of the box to the left of each section before continuing. Doing so verifies you have read and understand the statements below.
Waiver of Liability
By checking this box and submitting this registration form, in consideration of your acceptance of my entry, I, intending to be legally bound, hereby, for myself, my heirs, and my executors, waive and release the JACKSON YOUTH WRESTLING PROGRAM, it's volunteer coaching staff, the Ohio Youth Wrestling League and it's officials, from any and all claims of rights and damages for injuries or losses suffered by me directly or indirectly, in training for, traveling to and from, or competing in or attending the said wrestling program.
Medical Release
By checking this box and submitting this registration form, I hereby give my consent and authorize the coaching staff for the JACKSON YOUTH WRESTLING PROGRAM to give permission for any first aid or medical treatment deemed necessary for my child/children listed on this registration as a result of injuries sustained while participating in any activity, match, or functions sanctioned by the JACKSON YOUTH WRESTLING PROGRAM.