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Waiver & Medical Info

This page contains medical information forms and a waiver and release from liability form.

Parent's Medical Instructions
Medical History Questionnaire
Participant's Waiver & Release From Liability Form

These forms are required to train at Rattlers and kept for one year.

Wrestler's Name *

Date of Birth

Parent/Guardian Name *

Parent/Guardian Phone

Parent/Guardian Email *

Relationship

EMERGENCY CONTACT

Emergency Contact *

Emergency Contact Number *

Relationship *

MEDICAL INFORMATION

Insurance *

Policy Number *

Family Doctor

Phone

Is your wrestler presently on medication? *

Medication(s)

Drug Sensitivities & Other Allergies

PARENT/GUARDIAN CONSENT

Read and select one for consent *

Confirm Parent/Guardian Consent *

I confirm the choice for medical consent is correct.

MEDICAL HISTORY

Have you ever had an epileptic seizure or been informed that you might have epilepsy? *YesNo

Have you ever been treated for diabetes? *YesNo

Has a medical doctor ever told you that you were anemic or had sickle cell anemia? *YesNo

Do you have or have you ever had high blood pressure? *YesNo

Do you have or have you ever had any of the following diseases? *Heart disease (rheumatic fever)Liver disease (hepatitis)Kidney disease (infections)Lung disease(pneumonia)N/A

Have you ever been informed by a medical doctor that you have asthma? *YesNo

Do you presently have an unrepaired hernia? *YesNo

Have you ever been "knocked out" or experienced a concussion during the past 3 years? *YesNo

Have you ever had an injury to your neck involving nerves, vertebrae (bones),or discs that incapacitated you for a week or longer? *YesNo

Have you had a shoulder dislocation, separation or other shoulder injury in the past 2 years that incapacitated you for a week or longer? *YesNo

Have you ever had surgery to correct a shoulder condition? *YesNo

Have you ever had an injury to your back? *YesNo

Have you ever been told that you injured the ligaments and / or cartilage of either knee? *YesNo

Do you have any chronic conditions that have not been mentioned above? *YesNo

Chronic Conditions

Waiver and Release from Liability

I do hereby represent that he/she is, in fact, the parent or legal guardian of and acting in such capacity agrees to the terms and conditions of the above stated waiver and release. *

1. I undersigned, on behalf of myself, for my child (if applicable), my heirs and next of kin, personal representative, agents, insurers, successors and assigns (all hereinafter "Releasers") hereby FOREVER RELEASE, DISCHARGE AND COVENANT NOT TO SUE USA Wrestling Inc, AAU (AAU Wrestling), EP Rattlers LLC, Zajk LLC, its insurers, its affiliated clubs, administrators, agents, directors, officers,
state organizations, members, committees, volunteers, all employees, and any and all participants, officials, referees, coaches, host clubs, sponsoring agencies, sponsors, advertisers, local organizing committees (and if applicable) owners, lessors and operators of premises used to conduct any sanctioned event, meet, practice or activity (all hereinafter "Releases") from any and all liabilities, claims, demands, causes of action or losses of any kind or nature, past, present or future, direct or consequential that I may hereafter have for PERSONAL INJURY, PERMANENT, TEMPORARY, TOTAL OR PARTIAL DISABILITY, DISFIGUREMENT, PARALYSIS AND ANY OTHER LOSSES OR DAMAGES TO PERSON OR PROPERTY OR DEATH, arising out of my participation in, attendance at or traveling to and from any sanctioned event or activity including, but not limited to, LOSSES CAUSED BY THE PASSIVE OR ACTIVE NEGLIGENCE OF THE RELEASEES, or hidden, latent or obvious defects in the facilities or equipment used.

2. Releaser understands and acknowledges that sanctioned activities and the sport of wrestling in general have inherent dangers that no amount of care, caution, training, instruction, supervision or expertise can eliminate. RELEASOR EXPRESSLY AND VOLUNTARILY ASSUMES ALL RISK OF PERSONAL INJURY, PERMANENT, TEMPORARY, TOTAL OR PARTIAL DISABILITY, DISFIGUREMENT, PARALYSIS AND ANY OTHER LOSSES OR DAMAGES TO PERSON OR PROPERTY OR DEATH, sustained while participating in, attending, preparing for or traveling to and from any sanctioned event, meet, practice or activity, including the risk of PASSIVE OR ACTIVE NEGLIGENCE OF THE RELEASEES, or hidden, latent or obvious defects in the facilities or equipment used.

3. Releaser acknowledges and fully understands that each participant in any sanctioned event, meet, practice or activity, including Releaser, will be engaging in activities that involve risk of serious injury, including permanent, temporary, total or partial disability, disfigurement, paralysis and any other losses to person or property, including death, and that severe social and economic losses may result not only from releaser’s own action, inactions or negligence, but also from the actions, inactions or negligence of other notwithstanding the rules of play or the condition of the premises or of any equipment used. Further Releaser acknowledges and fully understands that there may be other associated risks with such activities that are not known or not reasonably foreseeable at this time.

I ACKNOWLEDGE THAT I HAVE HAD SUFFICIENT OPPORTUNITY TO REVIEW THE PROVISIONS OF THIS DOCUMENT AND UNDERSTAND ITS PURPOSE, MEANING AND INTENT.

3048858073

8837 Charles Town Rd, Kearneysville, WV 25414

coach@eprattlers.club

EPRTC/EP Rattlers LLC

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