Woodstock Cyclones Wrestling Club

2017-2018 Woodstock Cyclones Medical Release Form

Medical Power of Attorney

I appoint the board members, coaches, the IKWF and its members, and associates of the Woodstock Cyclones Wrestling club as my attorney to act on my behalf for the purposes of securing medical treatment for my child. This special power of attorney shall only be valid from November 1st, 2016 until April 1st, 2017.

Wrestlers Name

* First Name:

* Last Name:

PARENT/GUARDIAN ELECTRONIC SIGNATURE

* Parent/Guardian First Name:

* Parent/Guardian Last Name:

* Todays Date:

I agree to all of the terms and conditions outlined in this waiver. *

EMERGENCY CONTACT INFORMATION

* First Name:

* Last Name:

* Phone #:

FAMILY PHYSICIAN

* First Name:

* Last Name:

* Phone #:

* Insurance Carrier:

* Policy #:

* indicates required fields

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2017-2018 Woodstock Cyclones Medical Release Form