Peters Township Youth Wrestling

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					                                       Peters Township Youth
                                       Peters Township Youth
                                       Wrestling Registration Form
                                       Wrestling Registration Form

Name: ________________________________ Address: ___________________________________

Age: __________ Birth date: _________________ Weight: ___________ Yrs Exp_____________

Grade/school: __________ Email Address: please print clearly__________ ___________________

Father’s Name _________________ Home Phone _______________ Cell Phone _________________

Mother’s Name _________________ Home Phone _______________ Cell Phone _________________

If your child is injured and you are not available, whom should we contact?

Name 1: _________________________________ Phone: __________________________________

Name 2: _________________________________ Phone: __________________________________

Family Medical Insurance: ____________________________________________________________

Preferred Hospital: __________________________________________________________________

It is understood that the coaches and assistants will only attempt to keep the injured child comfortable until trained medical services
arrive. In case of emergency, it is our procedure to call 911. If necessary, they dispatch an ambulance. Parents/guardians are
immediately notified as soon as practical (usually prior to emergency assistance.)

Medical History (Check all that apply)
( ) Concussion/knocked out             ( ) Leg/toe numbness             (   )   Catching/locking joints      (   )   Hernia/rupture
( ) Neck pain/neck injury              ( ) Fractured bones              (   )   Deep muscle bruise           (   )   Dental problems
( ) Arm/finger numbness                ( ) Joint dislocation            (   )   Muscle pulls                 (   )   Dental appliances
( ) Back pain/back injury              ( ) Trick knee                   (   )   Ligament sprain              (   )   Other: __________

Does your child have a history of or take medicine for any of these problems:
( ) Asthma/wheezing                    ( ) Bleeding                    ( ) Skin rash                         ( ) Blood disorder
( ) Allergy                            ( ) Fainting/blackouts          ( ) Boils                             ( ) Loss of eyesight
( ) Heart problems                     ( ) Hyperventilation            ( ) Hearing                           ( ) Other: __________
( ) Diabetes/high-low sugar            ( ) Seizures                    ( ) Kidney condition

Is your child allergic to any medicines? If yes, please list: ______________________________

As a parent/guardian of ______________________________, I confirm that the information given is correct and hereby give my
permission for his participation in Youth Wrestling. I fully understand that I retain responsibility for medical care and related expenses
resulting from any accident, injury or medical and/or dental expenses incurred during the course of the program. I hereby release and
discharge Peters Township, the School District, all staff or agents, instructors and assistants from any and all actions, claims and
demands, damages, costs, loss of services, expenses and compensation which may result from injuries which may occur to my son in
the course of his participation.

Signed: ____________________________________________ Date: _________________________

Printed Name: _________________________________ Relationship to wrestler: _______________


$75 Registration Fee X _____ (# children) = ________ (total registration fee)
Check number:_________________ PayPal Transaction No>____________________
***** a Pay Pal processing fee is included in the on line registration fee
                                PTYWA ParenT volunteers
                                PTYWA ParenT volunteers



There are numerous opportunities for parents to volunteer during the season. Please review the
following and let us know which areas you could be of assistance.


Coaching *** Must have Child Abuse Clearances PRIOR to the start of                    ____
Practice


Group Coordinator- 2-4 parents from each group to coordinate pictures,                 ______
concession duties, match volunteers, fundraising etc.


Fundraising                                                                             _____
We are planning a “Night at the Races” fundraiser. There are
opportunities to help with set-up, collecting tickets, selling auction tickets
working the races etc.


Match Meetings                                                                          _____
Match our wrestlers to other wrestlers in different programs by age weight and skill
level for upcoming matches.



Banquet                                                                                 ____




Name ___________________________________________________________________


E-Mail ___________________________________________________________________


Phone Number ____________________________________________________________

Child’s name ______________________________________________________________

				
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posted:1/7/2012
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