PCWC Registration Fall 2017

2017-2018 Plymouth Canton Wrestling Club Registration Form
If your child(ren) will wrestle for their middle school while participating in our program, please use the "MS" (Middle Schooler) pricing below.
How Many Wrestlers

(Required)

Please select the number of wrestlers that you will be signing up today.

How many wrestlers are you signing up?

Wrestler 1 (First Name)

(Required)

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Wrestler 1 (Last Name)
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Date Of Birth

(Required)

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Please click enter birth date: You can type: MM/DD/YEAR or use popup.

Grade

(Required)

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Child 1 School

(Required)

Please list your child's current school.

Shirt size for this wrestler?

(Required)

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Wrestler 2 (First Name)

(Required)

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Wrestler 2 (Last Name)
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Please enter birth date: You can type: MM/DD/YEAR or use popup.

Grade

(Required)

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Child 2 School
Please list your child's current school.

Shirt size for this wrestler?

(Required)

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Wrestler 3 (First Name)

(Required)

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Wrestler 3 (Last Name)
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Grade

(Required)

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Child 3 School
Please list your child's current school.

Shirt size for this wrestler?

(Required)

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Parent Information:
Parent/Guardian (First Last)

(Required)

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Home Address

(Required)

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City

(Required)

Please enter your city name. Letters only.

Home Phone
Please enter a phone number where you can be reached.

Cell Phone
Please enter a valid 10 digit phone number.

E-Mail Address

(Required)

Please enter a valid email address

Additional Emergency Contact:
Emergency Contact Name
Please enter First and Last name of an emergency contact.

Emergency Contact 1 Phone Number
Please enter a valid 10 digit phone number.

Relation to child
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Medical Info
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For the wrestlers on this form, please list any chronic illness, allergies or any other condition that our staff needs to be aware of.

Medical Insurance Company?
Please enter your insurance carrier.

Insurance Company Phone Number?
Please enter your insurance carrier phone number.

Contract Number
Please enter your contract #

AUTHORIZATION FOR PUBLICATION OF IMAGES/VIDEOS

I give the Plymouth Canton Wrestling Club permission to use photographs and videos of above named wrestler(s) on the club web site, YouTube channel, and printed materials.  I understand that I will not be compensated for any such publication.



“PLEASE SUPPORT OUR EQUIPMENT DONATION PROGRAM”

WE ARE LOOKING FOR USED WRESTLING SHOES WE THEN MAKE THEM AVAILABLE FREE OF CHARGE AT THE START OF EACH SEASON TO THOSE WHO NEED THEM

 

I do hereby release the Michigan Youth Wrestling Association (MYWAY)and Plymouth Canton Wrestling Club of any responsibility for injury or illness.
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