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Midlothian Miners Wrestling Club
Waiver of Liability and Release Form
This form must be completed for each wrestler (participant) and, if the wrestler is under 18years old, must be signed by his or her parent or legal guardian. No wrestler will be allowed to
participate in wrestling practices, competitions, or events without this form, properly executed,
and on file.
PARTICIPANT’S NAME (type or print): ________________________________________
PARTICIPANT’S DATE OF BIRTH (mm/dd/yyyy): _______________________________
I, the undersigned, in consideration for my (or my minor child’s) voluntary participation in
organized wrestling with the Midlothian Miners Wrestling Club, do hereby willfully acknowledge
that my signature below attests to my understanding and agreement that:
My (or my minor child’s) participant status will be kept in good standing. I (or my minor child)
will not compromise myself in such a way as to do harm to the Midlothian Miners Wrestling
Club, knowing that participants may be dismissed from participation, with possible loss of
payment or dues, for violent conduct or unsportsmanlike behavior on or off the wrestling mat. I
agree to pay for any and all damages to any property or indemnities caused by me (or my minor
child) willfully, negligently, or otherwise.
Wrestling is a physical, contact, sport that involves the risk of injury. I assume all risks and
hazards associated with my (or my minor child’s) participation in the sport. I am (or my minor
child is) in proper physical condition to participate in wrestling practices, matches, meets and
tournaments, and I have (or my minor child has) no illness, disease or existing injury or physical
defect that would be aggravated by my (or my minor child’s) participation. I will inform my (or
my minor child’s) coach if this status changes. I further acknowledge that this risk may involve
loss or damage to me (or my minor child) or my (or my minor child’s) property, including the risk
of death, or other unforeseen consequences, including those which may be due to the
unavailability of immediate emergency medical care. I have (or my minor child has) a current
medical consent form in force. I (or my minor child) will wear properly-fitted and appropriate
shoes, and other protective equipment (e.g., mouth-pieces, head gear, etc.), as required by the
applicable wrestling rules, to all events.
The Midlothian Miners Wrestling Club does not have personal injury insurance that covers my
(or my minor child’s) participation. Therefore, I (or my minor child) should have a current,
active, personal injury insurance policy in force, which covers my (or my minor child’s)
participation. Under any condition, I am responsible for any and all medical expenses arising
from my (or my minor child’s) participation, both in practices and games and while travelling to
and from these events. I have the right and responsibility to inspect the equipment and facilities
prior to events and, if I believe (or my minor child believes) that anything may be unsafe, I (or
my minor child) will advise the coach or supervisor of the condition and may refuse to
participate. Participation assumes consent.
I do/ do not (CIRCLE ONE) authorize my (or my minor child’s) photograph, picture or likeness,
and/or voice to appear in any documentary, promotion (including advertising), television, video,
internet, or radio coverage of Midlothian Miners Wrestling Club practices, matches, meets,
tournaments, or other events, without compensation.
I authorize that an unaltered copy of this form may be generated and given to the officers or
directors of other leagues or tournaments in order to allow my (or my minor child’s) participation
in their wrestling programs, if the form is required and I have (or my minor child has) requested
to participate.
I hereby release, waive liability, discharge, hold harmless, indemnify, and covenant not to sue,
the Midlothian Miners Wrestling Club, its associated directors, administrators, officers,
managers, employees, coaches, trainers, volunteers, sponsors and advertisers, and other
agents, estates or executors, from any and all liability incurred in the conduct of, and my (or my
minor child’s) participation in, Midlothian Miners Wrestling Club wrestling programs and events.
This includes owners, lessors, and lessees of premises, municipalities, government agencies,
successors, heirs, and assigns.
I have completely read this document and fully understand its contents. I acknowledge that I
have (or my minor child has) given up substantial rights by accepting this document and that I
do so voluntarily. My signature attests to this on behalf of myself (or my minor child) and my
executors, personal representatives, administrators, heirs, next-of-kin, successors, and assigns.
For those individuals eighteen (18) years of age and older:
___________________________
__________________________
_______________
Participant’s Name (PRINT)
Participant’s Signature
Date Signed
For those individuals under the age of eighteen (18) years (minor):
As the parent and natural guardian or legal guardian of the participant, I hereby agree to the
foregoing Waiver of Liability and Release for, and on behalf of, the participant (wrestler/minor)
named above. I hereby bind myself, the minor, and all other assigns to the terms of the Waiver
of Liability and Release. I represent and certify that I have the legal capacity and the authority
to act for, and on behalf of, the minor in the execution of this Waiver of Liability and Release.
___________________________
__________________________
Parent or Guardian Name (PRINT) Parent or Guardian Signature
_______________
Date Signed