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Dubuque Wrestling Academy, LLC dba World Wrestling Camps
2010 Summer World Wrestling Camps
CAMP I June 27-30, 2010 (Wisconsin Dells, WI) CAMP II July 28—31, 2010 (Dubuque, IA)
Read, Complete, Sign & Return with Registration & Check. This completed form is REQUIRED prior to first session of camp. Mail to DUBUQUE WRESTLING; 2345 Sunnyslope Drive; Dubuque, IA 52002
Camper’s Last Name: ____________________________________________________________________________
First Name: ____________________________________________________________Male/Female:_________________________
Date of Birth: ____/____/____ Grade: _____ Parent’s Full Name:___________________________________
Home Phone: __________________________________ Cell Phone:____________________________________
Emergency Contact: ___________________________________________________Phone:_________________________________________
1. Does Camper have limitations regarding activities? (explain)__________________________________________________________________________________________
2. Does Camper have any special needs that we should anticipate? (For example, ADHA, allergies, special diet, mental or behavioral challenges) If yes, please explain: ____________________________________________________________________________________________________
3. Medications: Name/dosage/frequency needed. All medications must be in prescription bottles. Dosages/frequencies must match doctor’s prescription. Bring only amount of medications needed at camp. Medication Dosage Frequency
___________________________________ _______________________________ _________________________________
My child may have Tylenol or Ibuprofen (circle one): YES or NO
I am the parent or guardian having control or custody of the above named child. I hereby grant my child permission to attend World Wrestling Camps. I certify that my child is physically and mentally fit for all camp activities and will obey all camp counselors and rules. I certify that comments, photographs or videotape pictures of my child participating in the World Wrestling Camps may be reproduced and utilized in camp brochures and other promotional literature published and used by the camp. I understand and certify that my child’s participation in camp at World Wrestling Camps and its activities is completely voluntary. I have familiarized myself with the camp’s programs and the activities in which my child will participate. I recognize that certain hazards and dangers are inherent in the World Wrestling Camps events and programs including, but not limited to, swimming, jogging, wrestling, and conditioning. I acknowledge that although World Wrestling Camps has taken safety measures to minimize the risk of injury to camp participants, World Wrestling Camps cannot insure or guarantee that participants, equipment, premises and/or activities will be free of hazard, accidents and/or injuries. In case of moderate to serious injury, accident or illness of my child, I grant my permission for a licensed physician to treat my child. In cases of minor or mild injury, accident or illness of my child, I grant my permission for him/her to be treated by a member of World Wrestling Camps staff. I agree to pay all expenses for necessary treatment. I understand that World Wrestling Camps does not provide medical/liability insurance. I further recognize and have instructed my child in the importance of knowing and abiding by the camp’s rules, regulations and procedures for the safety of camp participants. I also give the camp full authority in dealing with problems of discipline. I understand that any camper demonstrating a willful disregard for camp rules is subject to being sent home with no refund of camp fees. I understand that any camper who willfully destroys property will be held responsible and charged accordingly. I also give my permission for the camper to participate in all activities as they pertain to his/her particular program. Further, I RELEASE WORLD WRESTLING CAMPS, AND ITS OFFICERS, DIRECTORS, AGENTS, REPRESENTATIVES, EMPLOYEES, VOLUNTEERS, SUCCESSORS, AND ASSIGNS, FROM ANY AND ALL RESPONSIBILITY, LIABILITY, OR CLAIMS INCLUDING, BUT NOT LIMITED TO, ANY CLAIMS BASED UPON ALLEGED NEGLIGENCE, FOR PERSONAL INJURY, DAMAGES, ACCIDENT, OR ILLNESS INCURRED BY MY CHILD, ARISING FROM OR RELATED TO MY CHILD’S PARTICIPATION IN ANY ACTIVITY AT OR CONNECTED WITH WORLD WRESTLING CAMPS. I understand that every effort will be made to protect and safeguard all campers. I agree not to hold World Wrestling Camps liable for any illness or mishap from any cause whatsoever. I approve this application and agree to the terms stated above. I represent that I am the parent or legal guardian of the child listed above, that I am at least eighteen (18) years of age and I am under no mental or legal disability which would prevent me from signing and executing this Waiver and Release. I further represent that I have read (or have had read to me) this Waiver and Release and understand its terms.
___________________________________________________ _________________________________________________ Name (printed) Name (Signature) & Date
