Wrestler's Name: ______________________________

Address: _____________________________________

City:    ___________________         State: _______ Zip: __________

Date of Birth: __________________

Home Phone: (_______) ______________

Emergency Contact:________________________

Emergency Phone: (_______) _______________

I give my son permission to attend and participate in the 1000 Islands Summer Duals on August 1st, August 2nd, and August 3rd  2008. I understand that his participation in this event involves risks and dangers that could result in serious bodily injury. I also understand that the Eastern Ontario Wrestling Club and its staff will not assume any responsibility for any accidents, medical or dental, or any other expenses incurred as a result of injury during this event. I verify that my child has medical insurance and a physician has determined he is physically able to participate in the 1000 Islands Duals and Clinics. I agree to allow my child to be treated by a certified trainer or licensed physician while attending (if necessary).

  
______________________________________ __________
Parent / Guardian Signature                                   Date

______________________________________    _____________
        Medical Insurance Company             Policy #