Youth Athlete Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name *

First Name

Last Name

Primary Phone # *

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Acknowledgement *

Parkersburg Cougars Youth Wrestling Club reserves the right to remove the wrestler from the program if, in the opinion of the coaching staff, the wrestler is not physically or mentally mature enough to compete in practice or tournaments at a level needed to prevent injury or distraction. By submitting this registration, you acknowledge that you have read and agree with the above statements and the information provided on this form, is accurate to the best of your knowledge. All parents/guardians will be required to complete USA Wrestling release and waiver of liability, assumption of risk, and indemnity agreement with parental consent prior to their child attending their first practice.