Wrestler's Name: ______________________________

Address: _____________________________________

City:    ___________________         State: _______ Zip: __________

Date of Birth: __________________

Home Phone: (_______) ______________

Emergency Contact:________________________

Emergency Phone: (_______) _______________

We give our son permission to attend and participate in the 1000 Islands Summer Duals on July 29 thru July 31 &/or August 5 through 7.  We understand that his participation in this event involves risks and dangers that could result in bodily injury, disability, paralysis, or death.  We hereby release, waive, discharge, and agree not to sue the Eastern Ontario Wrestling Club and/or its staff for any bodily injury, disability, paralysis, or death incurred as a result of participating in this event.  I verify that my child has medical insurance and that a physician has determined he is physically able to participate in the 1000 Islands Duals.  I also agree to allow my child to be treated by a certified trainer, emergency medical technician, or a licensed physician while attending (if necessary).

  
______________________________________                       ____________
            Parent / Guardian Signature                                            Date