CLINIC WAIVER

Owen High School Fall Wrestling Clinic Waiver and Release Form

Name________________________ School________________________

Address____________________________________________________

City________________ State__________ Zip__________

Home Phone (       ) ______________Age__________

PARENTS OR GUARDIANS WILL BE CONTACTED IN CASE OF AN EMERGENCY

WAIVER AND RELEASE: In consideration of my application accepted, I intending to be legally bound, do hereby,
for myself, my heirs, executors and administrators, waive, release and forever discharge any and all rights and
claims for damages, which I may have or which may be hereafter accrue to me against Owen High School or assigns,
for all damages which may be sustained or suffered by me in connection with my association with or participation in,
and for arising out of my traveling to or returning from said Kevin Jackson Wrestling Clinic. The camp director has
permission to seek medical attention of our son/daughter and I grant permission for the physicians and staff at the
local hospital to provide medical treatment in the event of injury or sickness.

Signed_________________________________( Participate )

Signed_________________________________( Parent/Guardian )

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Make Checks Payable to: POWERHOUSE WRESTLING CLUB

Mail To:    Power House Wrestling Club
                   10 Dogwood Ridge Rd
                   Candler, NC 28715

Cost:    $50 Pre-Registration, $60 at the door. $20 for Coaches.
             $45 (With a Valid USA Wrestling Card and Pre-Registered)

Coaches free with 5 or more wrestlers

***Team Rates available also***for 10 Wrestlers or more (Call for pricing)

Last Day to Pre-register is, October 1st 2010.

You may Fax or Email Waiver via the information below.

FOR ADDITIONAL QUESTIONS AND INFORMATION PLEASE CONTACT:

Jeff Foster
Owen High School
Home- 828-665-8138
Cell----828-231-5877
Fax----828-665-6591
coachjefffoster@yahoo.com