Signature of parent/guardian_________________________________________________________
Name Last:
First:
M.I.
Address:
Membership Registration Form
City:
State:
Zip:
Birthdate:
Age as of May 31, 2006:
School as of Sept 2006:
Grade as of Sept. 2006:
E-mail:
Screen name:
Home phone:
Cell phone:
Mother's name:
Cell phone:
Father's name:
Cell phone:
Mother's wk:
Father's wk:
Parent's E-mail(where you want information sent):
Emergency contact Name:
Phone:
Physician name:
Phone:
Address:
City:
Primary Insurance Carrier:
State:
Zip:
Address:
City:
Name of main policy holder:
Policy #
Phone:
State:
Zip:
do hereby grant permission for my child to be a member of the USA Wildcats. I also acknowledge the risks involved and assume those risks. I further hold harmless, the Cheerleading Training Center, USA Wildcats LLC, its affiliates, coaches, students and associated officers for any injury or sickness which is sustained as a result of my child's participation in this activity.
I also grant permission for the medical personal selected by USA Wildcats LLC, directors, coaches, or staff to provide any reasonable and necessary treatment, including X-rays if I cannot be reach in case of an emergency.
I
the undersigned parent/guardian of
Additional Comments, or Medecial Conditions you feel we need to be aware of:
