Oregon Youth Wrestling Club - (Oregon, WI) - powered by LeagueLineup.com

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2024/2025 Youth Wrestling Season

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

* Birthdate:

* Grade:

Gender:

* USA Card Number from registering at www.usamembership.com:

* Level of Experience:

PARENT/GUARDIAN #1

* Firstname:

* Lastname:

* EMail:

* Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

* Emergency Contact:

* Phone:

* Relationship to Player:

* Insurance Carrier:

Doctor Phone Number:

Medical Treatment and Medical History Questionnaire

* Chose One Giving Your Consent:

If my child needs medical attention, it is my wish that I am contacted before any medical treatment is given to my child, unless immediate treatment is necessary to save my child’s life or to prevent permanent injury

If my child needs medical attention, it is my wish that the medical treatment is started while efforts are being made to contact me. So that treatment is not delayed, I consent to any medical procedures that the physician believes are needed, on the understanding that efforts to contact me will continue to be made. I accept responsibility for all costs related to such treatment.

Food and Drug Allergies (please list specific food or medications; aspirin, sulfa, penicillin, etc.)::

Please list any medical condition(s) we should be aware of::

As a Parent and as an Athlete it is important to recognize the signs, symptoms,
and behaviors of concussions. By signing this form you are stating that you
understand the importance of recognizing and responding to the signs, symptoms, and behaviors of a concussion or head injury. This form must be completed for every sports season and every youth athletic organization the athlete is involved with.

Parent Agreement:

I have read the Parent Concussion and Head Injury Information and understand what a concussion is and how it may be caused. I also understand the common signs, symptoms, and behaviors.

I agree that my child must be removed from practice/play if a concussion is suspected. I understand that it is my responsibility to seek medical treatment if a suspected concussion is reported to me.

I understand that my child cannot return to practice/play until providing written clearance from an appropriate health care provider to his/her coach.

I understand the possible consequences of my child returning to practice/play too soon.

I/we agree with the above *

Please list all sports that your child participates in::

* Has athlete ever had a concussion?:

If yes, how many?:

* Has athlete ever had experienced concussion like symptoms?:

If yes, was it reported?:

Authorization for Photographs, Online Publication & Name Recognition
Please read the following statements and check ONE of the boxes.

I give permission for photographs and names of my child to be used in print and online publications promoting Oregon Youth Wrestling Club.

I do not give permission for photographs of my child to be used in publications promoting Oregon Youth Wrestling Club, including placement on the Oregon Youth Wrestling Club Website and Facebook page.

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