SPORTS MEMBERS INFORMATION

ALL FEES ARE NON REFUNDABLE OR NON TRANSFERABLE

WRESTLING SOFTBALL LACROSSE SOCCER CHEERING

First Name:______Middle:______Last:______

Age: ______DOB: ______/______/______Gender: ______Male ______Female Shirt Size: ______Singlet Size:______

Participant Lives with(Circle One): Both Parents Mother Only Father Only Grandparents Guardian 1parent/1step parent

Address:______City: ______

State:______Zip:______Home Phone: ______

Name of School:______Grade ______

RACE-NATIONALITY:

____ African-American ____ Native American ____Asian ____ Hispanic ____ Caucasian/White ____ Multi-Racial

____ Other ______

Is it OK to share your child’s information with volunteer coaches/ team assistants? YES NO

How many people are in Household?______

List all Siblings that attend the Club: ______

Is there a medical condition that prevents your child from participating in this program fully? ______

PARENT INFORMATION & HOUSEHOLD INFORMATION

Head of Household:______Cell Phone: ______Text Messages? YES NO

Email:______

Other Parent/Guardian:______Cell Phone: ______Text Messages? YES NO

Email: ______

Total income for Household

___ $0-$18,000 ___ $18,001-$24,000 ___$24,001-$26,000 ___$26,001-$28,000 ___ $28,001-$41,500 ___ Over $41,501

EMERGENCY CONTACTS:

This is someone who can who can assume temporary care of your child if we cannot reach you.

Name: ______Relationship to Child______Phone: ______

Release of Liability

I, the parent/guardian of the minor child listed on this application, for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge the Boys & Girls Club of Greater Gardiner, and Boys & Girls Club of America, their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organization such as staff, directors or volunteers, from all liability, claims, demands, or causes of action for any and all loss, damage, injury and any claim of damages resulting from use of facilities owned or controlled by the above organization, or participation in activities of said organizations either at or away from the Club.

I give permission to the Boys & Girls Club of Greater Gardiner to seek emergency medical treatment for my minor child if I cannot be reached. I will be responsible for any/all costs of medical attention and treatment. That includes emergency transportation.

I give permission for my child’s picture, moving pictures, or any other graphic depiction or likeness, to be used by the Boys & Girls Club of Greater Gardiner and its activities.

Are you interested in being a coach or assistant coach? YES NO If yes: Name ______

Parent/Guardian Signature ______Date ______

FORMS MUST BE COMPLETED IN FULL AND RETURNED TO THE CLUB IN PERSON OR BY MAIL WITH THE FULL PAYMENT.

FORMS WILL NOT BE ACCEPTED WITHOUT PAYMENT OR AFTER REGISTRATION DEALINE.

REGISTRATION DEALINE JANUARY 3RD, 2011

FOR ALL CANCELLATIONS OF PRACTICES OR GAMES PLEASE CHECK THE FOLLOWING:

FACEBOOK, OUR WEBSITE www.club4me.org, E-MAIL OR TEXT MESSAGES

WRESTLING 2011

REGISTRATION DEADLINE JANUARY 3RD, 2011

PROGRAM FEES:

Resident $45.00

Residents are participants that reside in Gardiner, West Gardiner, South Gardiner, Randolph and Pittston

Non-Residents $55.00

Non-Residents are participants that reside in all other towns

WHO:

For Boys & Girls in Grades 3rd, 4th, 5th, 6th, 7th & 8th.

WHAT:

Fundamentals of wrestling under the instruction of Matt Hanley, Wrestling Coach, Gardiner Area High School.

WHEN:

Practices: Monday & Thursday Night from 6-7:30

Program Begins on January 13th.

WHERE:

Boys & Girls Club Gym

FEE INCLUDES:

Long sleeve t-shirt, wrestling singlet and an award at the end of the season.

WRESTLING SINGLETS SIZES
XXXX-Small / XXX-Small / XX-Small / X-Small / Small / Medium / Large / X-Large / XX-Large
Chest / 19"-20.5" / 21"-22.5" / 23"-24.5" / 25"-26.5" / 27"-28.5" / 29"-30.5" / 31"-33" / 34"-36" / 37"-39"
Waist / 17"-18" / 19"-20" / 21"-22" / 22.5"-23.5" / 24"-25.5" / 26"-28" / 29"-31" / 32"-34" / 35"-36"
Hip / 19"-20.5" / 21"-22.5" / 23"-24.5" / 25"-26.5" / 27"-28.5" / 29"-30.5" / 31"-33" / 34"-36" / 37"-39"
Inseam / 2.75" / 4" / 5.25" / 6.25" / 7.25" / 8.25" / 9" / 9.75" / 10.75"
Weight / 40-55 lbs. / 55-75 lbs. / 75-95 lbs / 95-115 lbs. / 115-135 lbs. / 135-160 lbs. / 160-190 lbs. / 190-220 lbs. / Over 220 lbs.

14 Pray St. Gardiner, ME 04345 Phone: 582-8458 Website: www.club4me.org

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