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Pine Richland Wrestling Registration Form Name:__________________________________________________________________ Address:________________________________________________________________ Zip:____________ Phone:___________________________ Age:_________________ E-mail Address:__________________________________________________________ Date of Birth:______________________ Grade:__________ School:_______________ Weight:___________________________ Height:___________________ 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:________________________ Address:________________________________________________________________ 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 obligation check. 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 obligation check. Parent’s Signature:__________________________________________ 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.
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