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LEBANON MAT CLUB
Warrior Wrestling
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Wrestler's information
Wrestler's Legal First Name
Wrestler's Preferred First Name
Wrestler's Legal Last Name
Wrestler's Preferred Last Name
Wrestler's Street Address
City, State
Zip
Wrestler's Date of Birth
Age
Shirt Size
School (N/A if not attending school yet)
Short Size
Grade Level (N/A if not attending school yet)
Does the Lebanon Mat Club have your permission to post images/videos of your wrestler to our social media account(s) and website?
*
Yes
No
USA Wrestling Card Number
Parent/Guardian #1 Information
1st Emergency Contact
Parent/Guardian's First & Last Name (EC#1)
Relationship to Wrestler (EC#1)
Area Code
Parent/Guardian's Phone Number (EC#1)
Parent/Guardian's Email (only used for LMC correspondence) (EC#1)
Parent/Guardian #2 Information
2ND Emergency Contact
Parent/Guardian's First & Last Name (EC#2)
Relationship to Wrestler (EC#2)
Area Code
Parent/Guardian's Phone Number (EC#2)
Parent/Guardian's Email (only used for LMC correspondence) (EC#2)
eMergency contact information
two people other than the parent(s)/guardian(s) listed in the prior sections
Emergency Contact's First & Last Name (EC#3)
Relationship to Wrestler (EC#3)
Area Code
Emergency Contact's Phone Number (EC#3)
Emergency Contact's First & Last Name (EC#4)
Relationship to Wrestler (EC#4)
Area Code
Emergency Contact's Phone Number (EC#4)
medical information
Please fill out all information regarding your participant. All information will be kept confidential.
Insurance Company & Policy Number (N/A only if your participant does not currently have insurance)
Doctor's First & Last Name
Area Code
Doctor's Phone Number
Is your wrestler currently on any medication?
*
Yes
No
If so, please list medication(s):
Does your wrestler have any allergies?
*
Yes
No
If so, please list their allergy(s):
Please read the alternative statements below concerning the medical attention of your participant. (CHOOSE ONLY ONE)
*
If my participant 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 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.
If my participant needs medical attention, it is my wish that I am contacted before any medical procedures are taken on my participant, unless immediate treatment is necessary to save my participants life or to prevent permanent injury.
Date of your participants last complete physical examination by a medical doctor. If this is more than one year ago, please complete the following medical history questionnaire section.
I accept terms & conditions
Your wrestler has been successfully registered!
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