Registration

Caregiver Information

Full Name*

Phone*

Alternate Phone

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Child Information

Full Name*

Address (if different from Caregiver)

Street Address Address Line 2 City State ZIP Code

Date of Birth*

mm/dd/yyyy

Current Age*

Years of Experience*

Wrestling Division (if known)

Weight*

Which Season Are You Enrolling For?*

We will pro-rate fees for late registrations.

Child’s Medical Information

Medical Treatment Permission is included in the Release From Liability Waiver. Please provide this information in the event of an emergency. This information will remain confidential and will only be used in an emergency to provide to medical personnel for treatment purposes.

Physician’s Name*

Physician’s Number*

Physician's Address*

Street Address Address Line 2 City State ZIP Code

Health Insurance Provider*

Subscriber Name*

Subscriber’s Date of Birth*

Health Insurance Group Number*

Health Insurance Member ID*

Preferred Hospital*

Alleries

Emergency Contact

Name*

Phone*

Relationship to Child*

Conway Youth Wrestling Club

Caregiver Information

Child Information

Child’s Medical Information

Emergency Contact

RELEASE OF LIABILITY & MINOR CONSENT

READ CAREFULLY - THIS AFFECTS YOUR LEGAL RIGHTS

Conway Youth Wrestling Club

IMPORTANT LINKS

FAQs & Resources