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RIOT
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REGISTRATION FORM
Athlete Information
Child's Name
Sport
Choose an option
Parent/Guardian Name
Phone
Parent/Guardian Name
Phone
Email
Email
Address
City
State
Zip Code
EMERGENCY CONTACT
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Email
MEDICAL INFORMATION
Hospital/Clinic Preference
Physician's Name
Physician's Phone
Insurance Company
Insurance Company
I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither/guardian can be reached in the case of an emergency.
I give permission for my child to attend away games. I release The Riot Room and individuals from liability in case of accident during activities related to The Riot Room, as long as normal safety procedures have been taken.
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Wrestling Season (register before 11/1) - $350
Wrestling Season (register after 11/1) - $400
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