First Name (Athlete) *
Last Name (Athlete): *
E-mail Address: *
Select your Gold Membership * Attack System Youth Gold
Street Address: *
Address Line 2:
City: *
State: *
AL
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DE
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ME
MD
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WA
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-Terr.-
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Zip *
School *
Phone Number: *
Graduation Year (LAST 2 digits) *
Date of Birth (MM/DD/YYYY) * 1 2 3 4 5 6 7 8 9 10 11 12 / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907
Weight as of signup *
Years of wrestling experience * 5 or more 2-4 1st year wrestler
Accomplishments *
For the health safety and well-being of myself, as well as other wrestlers, I agree to abide by all aspects of the Attack System Health protocols for every program. * I agree I definitely agree
I agree to hold harmless Randy Simpson, staff, property owners and coaches, from and against any injuries sustained by the participant. The understanding hereby releases, waives, and forever discharges Randy Simpson and Randy’s Attack System Wrestling, LLC, from and against any and all claims, injuries, demands, actions, or cause of actions arising out of the participation by the athlete in Randy’s Attack System programs. I authorize the coach and/or staff to act in my behalf regarding any situation requiring discipline or medical attention. My son is physically fit to participate in this program, according to his family doctor. I agree to all conditions of the Attack System Gold Program. * I agree I definitely agree
Video release: I hereby grant permission to Randy’s Attack System Wrestling, LLC, the rights of my child’s image, in video or still, and of the likeness and sound of their voice as recorded on audio or video without payment or any other consideration. I understand that my child’s image may be edited, copies, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my child’s likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my child’s image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area. I agree I completely agree
No Refunds or Backouts! I understand that my deposit is non-refundable, due to the commitment level and exclusivity of this program, and the limited spots available. I also understand that I cannot back out of my agreement later or end my subscription early. If I do so I will still be responsible for the balance of my commitment. I agree I wholeheartedly agree and am ready to make this commitment!
Submitting this form constitutes a legal agreement to abide by all conditions mentioned in it. Name of Parent/Guardian agreeing to the above commitment: *
I also understand that I have the option of having my payment plan start the first week of September, or I can pay the balance by the beginning of September. I will make a full payment for the balance prior to the first week of September I will start the payment plan (51 weeks) the first week of September I authorize Randy Simpson to start the payment plan the first week of September, on the day of the week of my choosing.
* Required