Emergency Contact Information
Must be over the age of 18 and/or the parent/guardian of the above named athlete in order to sign
Parental/Guardian Waiver *
General Consent: I am over the age of eighteen (18) and am competent to execute this Waiver and Release relating to wrestler named above's participation in the Beat the Streets Wrestling Program of Providence (“BTSPVD”). I hereby grant permission for the wrestler named above to participate in the 2018-2019 BTSPVD program conducted all schools/sites within our programming. I understand that wrestling, a strenuous contact sport may, on occasion, cause injury. I also understand that participants with certain medical conditions could be impacted adversely by strenuous activity that increases the participant's heart rate, blood pressure, or breathing. I am responsible for ensuring that the wrestler named above is physically able to participate in youth wrestling and training activities, and I accept all risks of injury, whether to the wrestler named above or others, that may result from their participation in any BTSPVD event. I am not aware of any medical reason why the wrestler named above should not participate in the program. I authorize BTSPVD to act for me in the best interest of the wrestler named above in any situation, including (but not limited to) medical emergencies. In consideration for participation in BTSPVD programming or any organizational activities connected with BTSPVD, I waive any and all claims, demands, complaints, allegations, averments and other disputes I or the wrestler named above, or our agents, servants, heirs, assigns, representatives or successors may have or may in the future have as a result of participating in BTSPVD and the participation of others in my presence, or the condition or operation of the equipment, buildings or grounds. I further agree to hold Beat the Streets Wrestling Program of Providence, and its staff, directors, board members, coaches, parents and schools harmless from any liability or injury that may arise from the normal activities of this sport. Furthermore, I and the wrestler named above release any and all persons, including but not limited to BTSPVD, together with BTSPVD officers, directors, employees, coaches, shareholders, their respective agents, insurers, heirs, successors, attorneys, corporate affiliates and predecessors, from any and all claims, disputes, causes of action, which may arise out of any participation in BTSPVD by the wrestler named above or by others in their presence, or out of all acts or equipment, buildings or the grounds used by Beat the Streets. It is my intention in signing this Waiver and Release to give up forever any and all claims I or the wrestler named above may have against BTSPVD or its insurers, coaches, officers, directors, shareholders, employees, successors, affiliates and predecessors for any reason relating to BTSPVD.
Media Consent: I authorize the use of the wrestler named above's name and image in promotional or informational publications for BTSPVD, including on its website.
Data Release Consent: I authorize BTSPVD and BTS partner organizations with a mission to improve youth development outcomes, permission to collect the wrestler named above's identifiable student level data as part of any academic support and study that is sponsored by BTSPVD. This data includes but is not limited to: grades, attendance, state-wide exams, suspensions, serious incidents, enrollment, biographic, course and credit, fitness, and graduation rates.
I understand that this information is utilized as part of the BTSPVD reporting on the success of its wrestling and academic support program. I understand that this information will be used solely for evaluation purposes and will only be included in reports in aggregate form.
Intending BTSPVD to rely on this Waiver and Release, I warrant and represent that I have carefully read this Waiver and Release, that I have had the opportunity to confer with legal counsel of my choice concerning this Waiver and Release and the terms hereof before executing this document and before being involved in BTSPVD, and that I sign this Waiver and Release knowingly and voluntarily, intending to be legally bound hereby.
To be completed by student-athlete
How much like you or not like you is each statement listed below?