Application & Medical Release

Camper Information

Name: ___________________________________________________________

Address: _________________________________________________________

City/State/Zip: _____________________________________________________

Home Phone: ____________________________________

Business Phone:_________________________________

School attending with camp:_________________________

_______________________________________________

Coach attending camp home phone:__________________

Grade next year:_________________________________

Age at Camp:____________________________________

Weight at present time:____________________________

Weight class last year:_____________________________

School ranking (team camp):________________________

T-shirt size:   S   M   L   XL   XXL   (circle one)

Accident & Medical Insurance Company: _______________________________________

_______________________________________


Company Address: _______________________________

______________________________________________

Policy#:________________________________________

Policy Owner:____________________________________

Payment will be made by:

Parents      Students       Insurance     (Circle one)
 

Medical Release

This is the application for enrollment of (student’s name)

__________________________________

In Wrestle the World Outdoor Training Camp from June 1-5, 2005, I grant permission to the camp director, assistants or assigned chaperons of the camp to act on my behalf for said minor in granting permission for evaluation/treatment of minor medical problems.

I understand that should a major medical problem arise, an attempt will be made to notify me by telephone. In the event that I cannot be reached, I hereby give my consent to such medical treatment as deemed necessary by a licensed physician, such as x-ray examinations and anesthesia to be rendered to said minor.

In addition, I hereby release the Poma Ranch, its employees, all coaching staff members and volunteers harmless for any and all liabilities, actions, debts, or claims resulting from participating in the Wrestle the World Outdoor Training Camp. I also agree to grant permission for the Wrestle the World Outdoor Training Camp to use photographs of my son for publicity, advertising, or other commercial purposes.

This camp admits all qualified applicants without regard to disability, race, color, religion, national or ethnic origin, or sexual orientation.

I HEREBY CERTIFY THAT I HAVE READ AND
FULLY UNDERSTAND THIS AUTHORIZATION

Parent/Guardian Signature:

_______________________________________________

Date Signed:____________________________________

Allergic reactions to:
 ___________________________________________________________________

Medications taking:
 ___________________________________________________________________

I hereby certify that_______________________________ is physically fit to participate in an active wrestling program and that I know of no physical impairments which would in any manner limit his participation in such program.

*Doctor’s signature: _______________________________________________

Date signed: ____________________________________


*The doctor’s signature may be submitted by sending a copy of the camper’s physical (not more than one year old).

Make checks payable to "Wrestle the World"

Send camp applications to:

Wrestle the World
Attn: Dan Janowsky
PO Box 1735
Pagosa Springs, CO 81147