Pine Richland Wrestling Registration Form
Zip:____________ Phone:___________________________ Age:_________________
Date of Birth:______________________ Grade:__________ School:_______________
Number of Years Wrestling experience if any:_______________________
Is the child under any medical treatment? Yes No
If yes please explain:_______________________________________________________
Mother’s Name:_____________________ Father’s Name:________________________
Zip:_____________ Phone:_________________________ Email:_________________
In case of an emergency please notify:_______________________ Phone:___________
We herby authorize our child to join Pine-Richland Jr. Wrestling Program, we do release and forever
discharge any of the sponsoring organizations, its agents, employees, members, coaches, and all other
persons associated with the same from any and all claims, demands, actions, causes of action or legal
suits of any kind which might occur to us or our child because his/her participation in the Pine-
Richland Jr. Wrestling Program, including transportation of said child to and from the organizations
programs or activities. We understand that this release precludes any claims on behalf of said from his
participation. We also understand that due to the involved nature of the wrestling program, we agree to
participate fully in the association activities required for the successful completion of our season. This
includes volunteering to help in some capacity during home meets during the wrestling season. Failure
to fulfill these volunteer obligations will forfeit the return of our $75 volunteer /return of singlet
We fully understand the Pine-Richland Wrestling Association does not carry accident insurance and the
program is not sponsored by the Pine Richland School District and agree to use our own health care
insurance in case of injury to our child.
We certify that our child has had a physical examination within the past three (3) months and is
physically fit to compete in the Pine-Richland Jr. Wrestling Program without restriction.
We agree to properly care for and return, unaltered and undamaged, the uniform issued. If said
uniform is lost, stolen, or damaged, we agree to forfeit the return of our $75 volunteer/return of singlet
COMPLETE AND RETURN THE ATTACHED REGISTRATION FORM ALONG WITH
THREE CHECKS ($85 –REGISTRATION; $90 –RAFFLE TICKETS; $75 –
VOLUNTEER/SINGLET RETURN OBLIGATION ) PAYABLE TO PINE RICHLAND JR.
WRESTLING ASSOCIATION, THE EMERGENCY INFORMATION & MEDICAL CARE
AUTHORIZATION FORM AND A COPY OF YOUR SON’S BIRTH CERTIFICATE TO MIKE
BURNHAM 3003 SILVER OAK COURT GIBSONIA, PA 15044 BY SEPTEMBER 29 TH, 2007.