| REGISTRATION FORM : | LEBANON DIE-HARD WRESTLING |
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1st Contact:__________________________________Home:(____)_________Cell:(____)________ 2nd contact: __________________________________home:(____)_________cell:(____)_________ Address:__________________________________________________________________________ Email:__________________________________________Teacher:___________________________ Insurance co.:___________________________________________________policy#_____________ Family physician:_______________________________________________phone:(____)________ Emergency contact:___________________________________________phone:(____)________ Please list any physical or medical limitations this child may have:_____________________________ In case above listed cannot be contacted, I give permission for any emergency treatment to be administered. Signature:__________________________________________ Date:______________ Please X one of the following O Yes, you may use this child’s picture and or name on the Die-Hard wrestling web site. O No, you may not use this child’s picture and or name on the Die-Hard wrestling website. Hold Harmless Agreement I, the undersigned parent or legal guardian do hereby agree to allow the individual named herein to participate in the Lebanon Wrestling program. All persons participate in Town Recreation Programs do so without holding any Lebanon Instructor, volunteer or committee member responsible for any injury that may result during the course of any activity. I further agree that I will maintain in force, health and accident insurance to protect an hold harmless the town of Lebanon Wrestling volunteers and coaching staff against all loss, cost claims for bodily injury, or death resulting from any recreational activity provided to the above listed child. Signature:__________________________________________ Date:_________________________________ This program is for children in grades K-8, registration is as follows Kindergarten $30.00 Grade 1 - 6 $40.00 Grade 7 & 8 $30.00 NO REFUNDS ____________________________Please do Not write below this line______________________________ Weight:________Lbs. Shirt size:__________ Check #:___________________Paid cash:______________ |