Micky Phillippi-Registration

Micky Phillippi Clinic

PLEASE READ: Please fill out the following registration waiver for the Micky Phillippi Clinic on on August 29th. Space is limited so please do not wait.

* Indicates required field

Parent or Gaurdian *

First

Last

Email *

Address *

City *

State *

Zip *

Primary Phone *

Secondary Phone *

Participant Name *

First

Last

D.O.B (xx/xx/xx) *

Grade *

Weight (lbs.) *

Special needs/allergies *

Emergency Contact *

First

Last

Emergency Contact Phone *

$35 - Secure your Spot - Choose Payment method *

Venmo - @Wayne-Moda Check - To: Red Roots Wrestling Club

Check payments can be mailed to:
Wayne Moda
Red Roots Wrestling Club
15 Tibbetts Ave.
Danvers, MA 01923

Cancellation Policy: No refund will be issued within one week of start date.

Release *

I agree

I do hereby consent to participation in the Red Roots "Back to School" Clinic with Micky Phillippi and do forever release, acquit, discharge and covenant to hold harmless the Red Roots, Micky Phillippi and its successors, agents, servants and officers from any and all actions, causes of action, and claims, demands, damages, costs, on account of, or in any way growing out of, directly or indirectly, all known and unknown personal injuries or property damage which I/we may have now or hereafter have as the parent or guardian of said minor and also all claims or right of action for damages which said minor has or hereafter may acquire, either before or after reaching majority resulting from her/his participation of the Red Roots Wrestling Camp and/or receiving medical attention as provided herein; furthermore, I/we hereby agree to indemnify, reimburse or make good to the Red Roots Wrestling Club and/or its successors, agents, servants and officers any loss or damage or costs, including attorney’s fees, the Club or its representatives may incur if any litigation arises from said minor’s intentional, grossly negligent, or reckless acts or omissions while participating in said recreation programs. I/We understand that this program involves physical activity and hereby state that to my/our knowledge such minor is in proper physical condition for participation in such programs. I/We also agree to provide such minor with all the proper and required equipment to participate in such programs.

In the event of an emergency requiring medical attention, beyond first aid, I/we hereby grant permission to a physician or hospital personnel designated by the Red Roots Wrestling Club to attend to such minor.

Electronic Signature *

Submit

Click the "SUBMIT" button to complete the registration process.