Send to: Matrix Wrestling, 3546 Broadway, Allentown, PA 18104
For Information: Contact Matrix Wrestling At (610) 391-8915
WEB PAGE: https://matrixwrestlingclub.tripod.com/
E-Mail: matrixmatclub@yahoo.com
Name:___________________ _____ _______________________
Address:_____________________City_______________________
State______ Zip: ________ Telephone: (____)______-_________
Grade______ Birth Date ___________
Age ___ Weight_________
School _____________________ USA Card No. ______________
I grant permission my son/daughter to participate in the Matrix Wrestling program and agree
to hold harmless all coaches, officers, and the Schuykill Valley High School And Schuykill Valley 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_________
Parents/Guardian
Signature:_________________________________Date_________
