Mifflinburg Youth Wrestling Registration

Wrestler Information

Wrestler's Name: First Name: Last Name: Weight: Address: Date of Birth: Grade: Age: School Attending:

Parent/Guardian Information

Mother's Name: Mother's Home Phone: Mother's Cell: Father's Name: Father's Home Phone: Father's Cell: Guardian's Name: Guardian's Phone:

Primary Contact

Primary Contact: Relationship to Wrestler:

Additional Information

Siblings in Wrestling: Email: Do you text? Preferred Number for Texts:

Participation

Place a check next to the grades your wrestler has participated in the program (not this year):

Media Release

The Mifflinburg Area Wrestling team is committed to protecting the privacy of all student athletes and their families. The following is provided to offer you as a parent the right to choose whether or not your child may be photographed, videotaped or recorded for the local news media, publicity or for internal purposes, such as newsletter, school and district presentations, Wrestling Website, etc.. Please check one and return to your wrestlers coach or team mother.

I DO give permission I DO NOT give permission

We the parents/guardian of the above named participent hereby request and give complete permission to our child to participate in the Susquehanna Valley Elementary Wrestling League (SVEWL). We further declare that we desire that our child participate in this program and absolve and release all persons involved with the program, the Mifflinburg Wrestling Club and the Mifflinburg School District from any obligation and liabilities which may arise because of our child’s participation in the Susquehanna Valley Elementary Wrestling League (SVEWL). We understand that we could be responsible for any fees incurred by the club in result of our child not participating in a tournament he/she registered for. We also understand we are responsible for returning a team singlet and/or team jacket at the end of the season and we could be billed by the Mifflinburg Wrestling Club to recover such costs if the team singlet and/or team jacket is not returned

Signature:

By typing your name and submitting this form, you acknowledge that this action is equivalent to providing your signature and confirms your agreement to the terms and conditions outlined.: