Make Checks Payable to Matrix Wrestling Club
Total Amount_______Cash ______ CHECK#_______
SEND TO: Matrix Wrestling, 3546 Broadway, ALLENTOWN, PA. 18104
PHONE: (610) 391-8915 ask for BILL ALLEN
WEB PAGE: https://matrixwrestlingclub.tripod.com/
E-mail: mailto:matrixmatclub@yahoo.com
Name:_______________________________________
Address:______________________________City____________________________
State__________Zip:___________Telephone____________________
E-mail Address:________________________________
Grade______ Birth Date__________Age__________ Weight________
School_____________________________
USA CARD NUMBER:__________
I grant permission my son/daughter to participate in the Matrix Wrestling program and agree to hold harmless
all coaches, officers, and the __________________School District in the event of injury, which could occur during their participation
in the sport of wrestling. Further, I/ we authorize the Matrix wrestling representatives to provide emergency treatment of
injury and or illnesses of my/our child if qualified medical personal consider treatment necessary. This authorization is
granted only if I/we cannot be reached.
Wrestlers Signature: _____________________ Date:_________
Parent/ Guardian Signature:
___________________________ Date_______________
