First Name Last Name
Home Address City
State Zip
Parent/Guardian Home Phone
Cell Phone Email
DOB (mm/dd/yyyy)
Grade School
Health Insurance Company
Policy Number(s)
Family Physician
Date of last Tetanus shot
Date of last MMR (measles, mumps, rubella) immunization.
Was this a second immunization? yes no
Does the participant have any significant allergies?
Will the participant be taking any medications while attending the session? yes no
If yes, what (name and dose)
Are there special considerations with regard to this medication? yes no
Does the participant have any current or past history of a significant health problem (eg, diabetes, epilepsy, etc)? yes no
if yes please describe
Which camp are you attending?
JUNE 5-8 MIDDLE SCHOOL CAMP JUNE 8-11 FCA WRESTLING CAMP JUNE 16-20 HIGH SCHOOL CAMP 1 JUNE 23-27 YOUTH DEVELOPMENTAL CAMP JULY 6-JULY 10 HIGH SCHOOL CAMP 2 JULY 13-17 HIGH SCHOOL CAMP 3
I approve of my child’s participation in the Higher Calling Wrestling Camps and certify that within the past year he/she has had a physical examination and that he/she is in good health and able to participate in all Higher Calling Wrestling Camp activities. If medical attention is required for illness or injury while attending Higher Calling Wrestling Camps, I give my permission for such care and I hereby waive and release the Higher Calling Wrestling Club staff of all liability for any illness or injuries which may occur. I understand that any wrestler who does not abide by Higher Calling Wrestling Camp rules and regulations is subject to dismissal without reimbursement or recourse, and that damage to facilities will be assessed to those responsible.
I Agree
