(This form remains with Coach during season)

Student's Name *
Student's Name
Checkbox *
Davis Wrestling Club is authorized to have medical treatment for above listed athlete for whom I have financial responsibility. I have read/agreed to the "Agreement for Team Participation" and acknowledge that participation in athletics assumes risk of personal injury. I hereby give permission for the above athlete to receive the following medical treatment by: (check treatments you wish administered):
**Is the athlete subject to any conditions which may result in an emergency, such as: seizures; diabetes; severe allergies; asthma; heart condition; fainting; or other mental/emotional health problems? IF SO:
Emergency Contact Info:
GUARDIAN *
SELECT BEST CONTACT IN CASE OF EMERGENCY
Please provide the full name
Phone Number of Guardian *
Phone Number of Guardian
Insurance carrier
Coverage Dates:
Coverage Dates:
If known
Check all schools student will attend this school year *
Agreement
By digitally signing your first and last name & date this form, you are agreeing that the information submitted above is true and accurate and hereby submit this form as a legally bound document.
Date of Agreement
Date of Agreement