Membership Agreement

Team Delchev Trained Academy

Wendell Location
3050 South 1950 East
Wendell, ID 83355
Ph: (208) 536-1597
Email: fitnesselitetc@gmail.com

TO BE COMPLETED BY PERSONNEL ONLY

Member #
Key Tag #

All members must have a USA Wrestling card. Cards can be ordered on-line
at: www.usawmembership.com
Name:

Weight:

USA Wrestling Card #:

Division:
Date of Birth:

Mothers Name:
Mothers E-Mail:
Mothers Phone:
Mothers Occupation:

Fathers Name:
Fathers E-Mail:
Fathers Phone:
Fathers Occupation:
TO BE COMPLETED BY PERSONNEL ONLY

Credit Card/ Bank Draft Authorization

I hereby
authorize
TEAM D.T.A. to debit the amount
Initial
Payment
Method

Initial Payment Due Today

First Billing Date
Expiration Date
All payments are due every month. Membership privileges may
be suspended until past due amounts are paid.

of my dues/fees each month from my bank or credit

card account number
listed below in accordance
Cash
Check
Check# with
the terms and conditions of this membership
agreement. Additionally, TEAM D.T.A. will have the
Visa
Master Card
American
right to apply a statement
fee to my account
for
Express
any transaction not debited electron ally.
I
understand that I am in full control of my payment
obligations and options. I have read and understand
the Payment Obligations and Credit Card/ Bank
Draft Authorization.
Date of debit will be the 1st of the month Account to
debit:

I hereby consent to my childs (or self id 18 & over) participation in the TEAM D.T.A. program. I agree to
Visa
MasterCard American Express
indemnify
Name(s) as it appears on bank or credit card
account:
Credit Card #

Membership Agreement
and hold free and harmless TEAM D.T.A., its officers, coaches, and officials from any and all liability
against them arising out of my childs participation therein, whether liability is caused by, or arose out
of negligence. USA provides secondary medical coverage through their membership.
I have read and fully understand the above Program Details, Waiver and Release of All Claims.
Signature of parent/guardian or self (if 18 and over).
Date:

Print Name:

For good and valuable consideration, the receipt of which is hereby acknowledged, I hereby consent to
the photographing of myself and recording of my voice and the use of these photographs and/or
recordings singularly or in conjunction with other photographs and/or recordings for advertising,
publicity, commercial or other business purposes. I understand that the team photograph as used
herein encompasses both still photographs and motion picture footage.

I further consent to the reproduction and/or authorization by TEAM D.T.A. to reproduce and use said
photographs and recordings of my voice for all domestic and foreign markets. Further, I understand
that others, with or without the consent of TEAM D.T.A. may use and/or reproduce such photographs
and recordings.
I hereby release TEAM D.T.A., and any of its associates or affiliated companies, their directors, officers,
agents, employees, and customers, and appointed advertising agencies, their dictators, officers,
agents and employees from all claims of every kind in account and such use.
If wrestler is under 18: I,
am the parent/legal guardian of the individual
named above, I have read this release and approved of its terms.
Signature of parent/guardian or self (if 18 and over):
Date:

Printed Name: