SPENCERPORT JUNIOR RANGERS WRESTLING CLUB 2013-2014 REGISTRATION

Practice Days and Location

Tuesday and Thursday* Auxilary Wrestling Room at the EJ Wilson High School * as long as school is in session and the wrestling room is available.

Grades, Time and Cost	K - 2nd grade 6:30pm - 7:45pm 11/12, 11/14, 11/19, 11/21, 11/26, 12/3, 12.10, 12/12, 12/17 and 12/19 $60 per wrestler	3rd- 6th grade 6:30pm - 8:00pm 1/7, 1/9, 1/14, 1/16, 1/21, 1/23, 1/28, 2/4, 2/6, 2/11 and 2/13 $60 per wrestler
	Includes instruction, practice, team t-shirt, secondary insurance coverage.

Suggested Apparel (not required)

Wrestling sneakers, head gear and knee pads. Gym sneakers are ok. For sanitary reasons, please do not wear your sneakers to practice.

Registration Choices:

Sign up online (strongly suggested) or at the first practice. If registering online, fill out the form below and select Google Checkout. Google Checkout allows you to pay with a Debit or Credit Card. There is no fee to you for this option.

REGISTRATION

Wrestlers First Name

Wrestlers Last Name

Age

--- 5 6 7 8 9 10 11 12 Other

Grade

--- K 1 2 3 4 5 6

Wrestlers D.O.B.

--- 01 02 03 04 05 06 07 08 09 10 11 12   --- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   --- 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

School

--- Bernabi Canal View Cosgrove Munn Terry Taylor Other

Approx Weight

lbs.

Parent/Guardian 1

Parent/Guardian 2

Address

City and Zip

Home Phone

Cell Phone

Email

T Shirt Size

--- YS YM YL AS AM AL AXL

Insurance Provider

Insurance Policy

Physician's Name

Physician's Phone

Is your child alergic to any medicines?

--- Yes No

If yes, explain:

Does your child have asthma, diabetes or epilepsy?

--- Yes No

If yes, explain:

Is your child on any medicines?

--- Yes No

If yes, explain:

Does your child wear contacts?

--- Yes No

Is there anythig else we should know about your child's health or physical condition?

--- Yes No

If yes, explain:

Consent Form

I hereby give my permission for to participate in the Spencerport Junior Rangers Wrestling Club; to provide emergency treatment of an injury to or illness of my child, if qualified medical personnel consider treatment necessary and perform the treatment. This authorization is granted only if I can not be reached and a reasonable effort has been made to do so.

My child and I are aware that participation in wrestling is a potentially hazardous activity. I assume all risks associated with participation in this sport including but not limited to fall, contact with other participants, the effects of the weather, traffic, and other reasonable risks conditions associated with the sport. All such risk to my child are known and understood by me. I understand this informed consent form and agree to its conditions on behalf of my child. I do further release, indemnify and hold harmless the Spencerport Junior Rangers Wrestling Club, Spencerport School District, the organizers, and the supervisors and any and all of them.

I understand this informed consent form and agree to its conditions on behalf of my child. Typing my name, this is the equivalent of my signature: Today's Date --- October November December January --- 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 , 20 13 14

Payment Method

--- Google Checkout Check Payable to Spencerport Wrestling

Please fill out the info below as this will help us identify online payment to the wrestler

Name of Individual Paying