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INSTRUCTIONS
FOR USING FORM MEDICAL REPORT AND WAVIER FORM
For the health, safety and comfort of the participants, it is required
that this form be filled out
accurately. Please answer all questions. NAME:
___________________________________________
AGE: _________ SEX: ________
ADDRESS:____________________________________________________________________ POSTAL CODE:_____________________ PHONE NUMBER ___________________________ EMAIL:
__________________ SCHOOL:
___________________________ GRADE: ________ MEDICAL#
__________________________DATE OF BIRTH dd / mm / yy __ __ / __
__ / __ __ MEDICATION: If the wrestler uses medications, please list below:
GENERIC NAME:______________________________________________________________
DOSAGE:____________________________________________________________________
TIME GIVEN:_________________________________________________________________ ALLERGIES:
IS THIS PERSON SUBJECT TO ALLERGIES: YES: ________
NO: ________
SPECIFIC
ALLERGIES:_________________________________________________________
TREATMENT REQUIRED:______________________________________________________ _____________________________________________________________________________ IS
THIS PERSON EPILEPTIC: YES: ________
NO: ________ IF
yes, elaborate as to type, frequency, any factors likely to cause seizure, and
the effectiveness of Medication: IS
THIS PERSON A DIABETIC: YES: ________ NO:
________ IF
yes, please indicate any special diet:_________________________________________________________________________ HAS THIS PERSON
RECEIVED A TETANUS IMMUNIZATION: YES: _____ NO:
______ If
yes. When? ________________________________________________________________ Please
list any precautions or physical limitations that may affect your child's
enjoyment and learning. i.e. joint problems previous injuries, etc. If you have
any other information that may be of assistance to the coaching staff, we would
appreciate if YOU would inform us. __________________________________________________________________________ In
consideration of enrolment in the Central Okanagan Wrestling Association, I
waive and release any and all rights of claim for damages I may have or acquire
against COWA and its officers, agents, servants and employees for any and all
injuries, infections and sickness suffered by me and I acknowledge the rules
laid down by COWA governing its operation and that it remains the sole
responsibility of the participant to act and govern himself/herself in such a
manner as to be responsible for his/her own safety. NAMES OF ALL PARENT(S)
/ GUARDIAN(S): ___________________________________________________ PHONE
NUMBER IF DIFFERENT THAN ABOVE: ____________________________ ALL
PARTICIPANTS UNDER THE AGE OF 19 MUST OBTAIN PARENT(S)
/ GUARDIAN(S) CONSENT IN THE SPACE BELOW: CONSENT:
I, __________________________________do hereby declare that I am a parent or
legal guardian of the above participant in COWA. PARENT'S/GUARDIAN'S
SIGNATURE: __________________________________________ DATE
dd / mm / yy __ __ / __ __ / __ __
EMERGENCY
CONTACT OTHER THAN PARENT NAME:
___________________________________________ PHONE: __________________ NAME OF DOCTOR:
_______________________________ PHONE: __________________
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