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Sign up for exciting opportunities to wrestle in the City of Boston this Spring!
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Wrestler’s Full Name: _________________________________________________________
Birth Date: _____ / _____ / _____ Gender: ☐Male ☐Female
School: ________________________ School ID #: ___________________
Current Grade: ________ Weight: ___________ (best guess)
Shoe Size: _________ Shirt Size: YS YM YL S M L XL (circle)
Parent Name: ___________________________________________________________________
Home Phone: __________________________ Cell Phone: _____________________
Email: ___________________________________________________________________________
Home Address: _________________________________________________________________
In an emergency when parent/guardian cannot be reached please contact: Name: ________________________________________ Phone: __________________________
Please list any allergies the wrestler has: ____________________________________
Is the wrestler currently on any medication? ☐YES ☐NO If yes, list:
Has the wrestler been diagnosed with a concussion? ☐YES ☐NO If yes, when and how severe? _________________________________________________ Please list other medical conditions:
Physician’s Name: __________________________ Phone: ___________________________
Medical/Hospital Insurance Company: _______________________________________
Policy Holder’s Name: ______________________ Policy Number: _________________
Please attach a copy of your insurance card to this form. I hereby give my consent for the above named wrestler to participate in any Boston Youth Wrestling training sessions from April 1, 2013 to July 9, 2013. I recognize the possibility of physical injury associated with wrestling, which may include but is not limited to paralysis, permanent mental disability, and death, and hereby release, discharge, and otherwise indemnify Boston Youth Wrestling Inc., the employees and associated personnel of the organization, and affiliated organizations against any claim by or on behalf of the wrestler named above as a result of that wrestler’s participation in Boston Youth Wrestling programs and/or being transported to or from the same, which transportation I hereby authorize. I hereby give my consent to have an athletic trainer, coach, emergency medical technician, nurse, medical treatment facility, and/or doctor of medicine or dentistry or associated personnel provide the wrestler with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I understand treatment for injury will be based on information provided herein. I hereby authorize emergency transportation of the wrestler to a medical treatment facility should an individual listed above consider it to be warranted. I hereby authorize the use of the above named wrestler’s name and image in promotional publications for Boston Youth Wrestling. By signing below, I acknowledge that I have read, understand, and accept the above contractual agreements. Wrestler’s Signature: ____________________________________________________ Date: _____ / _____ / _____
Parent/Guardian Name (Please Print): ____________________________________________________________
Parent/Guardian Signature: ____________________________________________ Date: _____ / _____ / _____
Spring/Summer 2013 Off-Season Training Programs
www.bostonwrestling.org Find us on Instagram and Facebook! @bostonwrestling
Boston
Youth Wrestlin
g Application
and Waiver Form
BCYF Recreation Center Club at Madison Park
(In partnership with the Boston Center for Youth and Families) 75 Malcolm X Blvd. Roxbury MA 02120 (close to Dudley Square T
Bus Station and Roxbury Crossing Orange Line T Station)
• Saturdays starting April 27th until June 29th (10 weeks) 10:00am-1:00pm (5-7th grade practice runs from 10-11:30, 8th-12th grade practice runs from 11:30-1)
• Cost: FREE! Must register by completing form on back • Open to any residents of City of Boston in grades 5-12,
preference given to past participants of a Boston Youth Wrestling program
• Limited to first 40 wrestlers in both age groups (20 wrestlers in grades 5-7 and 20 wrestlers in grades 8-12)
• Focus will be on fundamentals, improved physical fitness and endurance, and fun!
Hyde Park Police Academy Wrestling Club
(In partnership with the Boston Police Department) 85 Williams Ave. Hyde Park MA 02136
• Mondays and Wednesdays starting April 1st until June 5th
(10 weeks) • Cost: FREE! Must
register by completing form on back
• Open to all wrestlers
• Contact: Coach Gibbons
Wrestlers that participate in either club this Spring are eligible to participate in BYW’s Summer wrestling!
Criteria for determining who will be eligible to participate in either summer opportunity will be based on attendance, scholarship, and citizenship.
BYW and BCYF will be sending Boston’s first ever “City” Wrestling Team to compete in the Annual Bay State Games at UMass-Boston on July 5-6, 2013. More information about the tournament can be found at www.baystategames.org/wrestling (registration fees and uniforms will be provided for team members chosen to compete, limit 25)
BYW, in partnership with BCYF and Boston University, is excited to offer several scholarships to attend the Carl Adams BU Wrestling Camp for FREE! More information for the camp can be found at www.carladams.com
Where can my child wrestle this Spring and Summer?
Boston Youth Wrestling’s mission is to develop
inner-city youth by inspiring personal, academic, and
athletic success through the sport of wrestling.
Check out our website!
www.bostonwrestling.org
Find us on Facebook and Instagram! @bostonwrestling
Questions? Contact Executive Director José Valenzuela
[email protected] 617-897-2097
