LCP Wrestling 2016-2017 Folkstyle Season

Personal Information (As of Aug. 31, 2016) Wrestler Name______Date of Birth ______Age ___

Approximate Weight ______Shirt Size ______

Parent/Guardian ______Relationship ______

Address ______City ______State _____ Zip ______

Home Phone ______Cell Phone ______

E-mail ______Alt. E-mail ______

Insurance Information

Primary Insurance Company ______Policy No. ______

Emergency Contact Information

Name ______Phone Number ______

Medical Information

List any known allergies ______List any medications taken on a regular basis ______Doctor’s Name ______Phone Number ______

I, ______(parent/guardian) hereby give consent for ______(wrestler’s name) to compete in amateur wrestling events, sanctioned by Texas USA Wrestling as a member of LCP Wrestling. My child and I are aware that wrestling is a potentially dangerous sport that may result in, but not limited to, serious injury, including permanent, temporary, total or partial disability, disfigurement, paralysis and any other losses to person or property, including death. I further release Texas USA Wrestling, Leander Independent School District, LCP Wrestling and any coach, board member or volunteer associated with LCP Wrestling from all liability for said injuries above.

If, in the judgment of the coaches or any representative/parent involved in LCP Wrestling, my child needs immediate care and treatment as a result of injury or sickness, I do hereby request, authorize and consent to such care and treatment as may be given to said child by any physician, trainer, nurse, hospital, or representative/parent of LCP Wrestling; and I do hereby agree to indemnify and save harmless any coach or representative/parent of LCP Wrestling from any claim by any person whomsoever on account of such care and treatment of said child.

Parent/Guardian Signature ______Date ______

For Club Use Only Date rec’d ______Amount rec’d ______Check # ______USA # ______

Texas USA Wrestling Age, Division, and Experience Level Certification 2015-2016

Wrestlers Name______Club______

Date of Birth______Age as of September 1, 2016______

Division (Circle One) Tot (Ages 4-5 - Born September 1, 2010 to August 31, 2012) D1 (Ages 6-7 – Born September 1, 2008 to August 31, 20010) D2 (Ages 8-9 - Born September 1, 2006 to August 31, 2008) D3 (Ages 10-11 - Born September 1, 2004 to August 31, 2006) D4 (Ages 12-13 - Born September 1, 2002 to August 31, 2004) D5 (Ages 14-15 - Born September 1, 2000 to August 31, 2002) D6 (HS - Born after September 1, 1997 and enrolled in high school) Experience Level (Circle one) Rookie 1st year wrestler; no wrestling match any style, anywhere, prior to March 15, 2016. Novice 2nd year wrestler; no wrestling match any style, anywhere, prior to March 15, 2015. Open 2+ year wrestler.

Note: “No wrestling match any style, anywhere” means the wrestler has not wrestled any wrestling match of any style including folkstyle, collegiate, freestyle, Greco Roman, or beach wrestling in any state or country. “Any style” does not include practices where no matches are wrestled or other styles of martial arts such as jujitsu, submission grappling, sambo, Shuai Jiao, tae kwon do, kung fu, karate, or other styles that include striking, kicking, punching or joint locking techniques.

I, ______, parent/guardian of the above named wrestler have provided the coach of the above named wrestling club with either a photocopy or certified copy of the birth certificate of the above named wrestler. I certify that it has not been altered in any way. I also certify that the experience level indicated above is accurate. I understand that falsification of any information on this form will result in disqualification from the above wrestler participating in any activity with Texas USA Wrestling for the remainder of the 2016- 2017 season. ______Parent/Guardian Date

I, ______coach of the above named wrestling club certify that I have received a copy of the above named wrestlers birth certificate and have verified that the birth date stated on this form is accurate. I also certify that I have discussed with the parent/guardian the experience level of the above referenced wrestler. I understand that falsification of any information on this form will result in disqualification from the above wrestler participating in any activity with Texas USA Wrestling for the remainder of the 2016-2017 season. ______Coach/Administrator Date