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Birthdate
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Parent Information
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Last
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Emergency Contact #1
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Last
Phone
Relation to Child
Emergency Contact #2
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Last
Phone
Relation to Child
List ANY Medical Conditions or Allergies
Parents' Instructions on Medical Treatments
Wrestler's Name
First
Last
Date of Birth
MM slash DD slash YYYY
Parent/Guardian Name
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Last
Relationship
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Please Indicate another person to call if an accident occurs and we are unable to reach you
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Is your child on any medication, have drug sensitivities or other allergies?
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If YES, please list the medications, sensitivities or allergies below
Date of your child's last complete physical examination by a medical doctor
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if this is more than a year ago, then you will be required to complete a medical history questionnaire
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Rebel Wrestling Club
South High School
1101 Planz Road
Bakersfield, CA 93304
contact@rebelwrestling.org
