POCONO SUMMIT YOUTH
WRESTLING ASSOCIATION
WRESTLING REGISTARTION AND RELEASE FORM
THIS FORM MUST BE COMPLETELY FILLED OUT ON BOTH SIDES FOR EACH WRESTLER
I hereby grant permission for my son/daughter to participate in the Pocono Summit Youth Wrestling Association’s activities for the 2011-2012
season. In case of accident, injury or illness, I hereby authorize the coaches to take the wrestler/cheerleader to a physician or the emergency
room of a hospital.
Wrestler’s Name: First _________________________________Last__________________________________
Birth date: ___________ Grade: ________ School: _________________
Warm Up Size (Circle One): YS
YM
YL
S
M
L
Weight ___________
XL
Parent’s Names: _____________________________________________________________
Home Address: _____________________________________________________
City: ______________________ State: ___________ Zip: _________
Home Phone #: ____________________ Cell Phone #: _______________________
Parent’s email address: __________________________________________________
EMERGENCY INFORMATION/MEDICAL CONDITIONS
In case of accident, injury or illness, I hereby authorize the coaches to take the above-named participant to a physician or the emergency room
of a hospital. Since the health of the participant is of utmost importance, it is imperative to know whether your child has any allergies,
handicaps or other health problems, of which the coaches should be aware. If so, please list here: (continue on back of form if necessary)
_________________________________________________________________________________________
____________________________________________________________________________________________________________
Name of Emergency Contact Person: ______________________________________
Contact Person’s Phone #: ______________________
Contact Person’s Cell #: ______________________
Family Physician: __________________________ Physician’s Phone #:____________________________
Is Participant Taking Medication? _______ If yes, please list _____________________________________________
Health Insurance Co: ______________________________________
Insurance Plan # ___________________________
Registration Payment: Cash / Check (circle one) Amount __________Check #__________
Registration Fee- ($95.00 first child, $85.00 second child,$75.00 each additional child)
Uniform Bond:
Cash / Check (circle one) Amount __________Check #______
$50.00 each child- will be returned once the uniform is returned
By signing below, I certify that I have read and understood this form, and that I agree with the guidelines set forth. I further declare that my
son/daughter participates in all Pocono Summit Youth Wrestling related activities at his/her own risk, and will not in any way hold liable the coaches, sponsors,
or officers of the Pocono Summit Youth Wrestling Association, or the Pocono Mountain School District for any injuries sustained while participating in any
Pocono Summit Youth Wrestling related activity.
Signature of Participant: ________________________________DATE____________
Signature of Parent/Guardian: ____________________________DATE____________
A COPY OF THE PARTICIPANTS BIRTH CERTIFICATE MUST BE RECEIVED BEFORE THEY MAY PRACTICE
POCONO SUMMIT YOUTH
WRESTLING ASSOCIATION
MEDIA/ INFORMATIONAL RELEASE
By signing this form I understand that:

Photos of participants may be published in local newspapers, PSYWA publications, and the PSYWA website.
If I find that I am against this, I will notify the board in writing prior to the start of the season.

Video footage of participants may be taken for coaching purposes, end of year videos, and family keepsakes. I understand that my
child may be filmed by individuals outside of the PSYWA and I will be vigilant so that no ill will is being done.

PSYWA primary information source is the internet and by email. PSYWA relies on this method
to keep members informed. Your information will be kept solely for use with PSYWA.

To be a PSYWA participant I must be a resident of Pocono Mountain West School District. At any
time the PSYWA may request proof. If I falsify any information, my participant(s) and I will be dismissed
from the program with no refund.

The PSYWA has a no refund policy and is in no way expected or required to give a refund for any reason.
Parent/ Guardian Name (Please Print): __________________________________________
Parent/ Guardian Signature: __________________________________________
POCONO SUMMIT YOUTH
WRESTLING ASSOCIATION
Wrestlers/cheerleaders code of conduct
1. I will participate to have fun and remember that the matches are fun
2. I will treat others competitors, coaches and spectators with respect regardless of race, creed, sex, or ability
3. I will inform a coach of any physical disability or ailment that may affect my performance, safety or the safety of another
4. I will encourage sportsmanship by showing respect and courtesy, and by demonstrating positive support for all players, coaches, officials and spectators at every match,
practice and any other team function
5. I will not engage in any kind of unsportsmanlike conduct with any official, coach, player or parent such as booing, and taunting, refusing to shake hands or using
profane language or gestures
6. I will not engage in or encourage any behaviors or practices that would endanger the health and well being of anyone
7. I will resolve conflicts without resorting to hostility, violence or negative behavior
8. I will never ridicule or taunt another participant for making a mistake or losing a competition
9. I will respect coaches and their authority during matches, practices, and tournament and will never question or confront a coach at the match, practice or tournament,
and will instead take time to speak to the coaches at an agreed upon time and place with my parents
10. I will demand a sports environment that is free from drugs, tobacco and alcohol and I will refrain from their use
11. I will treat opponents with respect by shaking hands prior to and after matches
12. I will respect the judgment of officials and abide by rules of the League
13. I will participate in a positive manner. I will not taunt or ridicule other competitors
14. I will participate in as many practices as possible
15. I will remember that practices are there to help me wrestle, they are not a social event
16. My friends will not be allowed to attend my wrestling practices unless they are also a PSYWA member
17. I will report to a coach or board member any infractions of any of the above rules so they may be investigated
Parents Code of Conduct
1. I will not force my child to participate in wrestling
2. I will accept the fact that my child may not be socially or developmentally ready for wrestling and I will respect the coaches judgment on choosing not to coach a child
who they feel is not ready for wrestling
3. I will remember that the children come to practice to learn, I, another guardian or parent will remain at all practices for the entire practice, if my child is in grade 2 or
younger
4. I will intervene if my child’s behavior is unacceptable at a match or practice
5. I will support the PSYWA disciplinary actions taken against my child by following through on discipline at home
6. I will remember that children participate to have fun and that the matches are for the children, not the adults
7. I will demand that my child/children treat other players, coaches officials and spectators with respect regardless of race, creed, sex or ability
8. I will inform a coach of any physical disability or ailment that may affect the safety of my child or the safety of others
9. I (spouse or my guest) will be a positive role model for my child and encourage sportsmanship by showing respect and courtesy, and by demonstrating positive support
for all players, coaches officials and spectators at every match, practice and any other club function
10. I (spouse or my guest) will not engage in any kind of unsportsmanlike conduct with any official, coach, player or parent by booing, taunting, or using profane language
or gestures
11. I will teach my child/children to play by the rules and resolve conflicts without resorting to hostility, violence of negative behavior
12. I will praise my child for competing fairly and trying hard, and make my child/children feel like a winner every time
13. I will never ridicule or punish my child or any other participant for making a mistake or losing a competition
14. I will respect coaches and their authority during matches, practices and tournaments and will never question or confront a coach at practice or match in front of the
children, and will take time to speak with coaches at an agreed upon time and place
15. I will demand a sports environment for my child that is free from drugs, tobacco and alcohol and I will refrain from use at all practices, matches and any club function
I hereby agree that if I fail to conform my conduct to the foregoing while attending, coaching, officiating or participating in a Pocono Summit Youth Wrestling Association event I
will be subject to disciplinary action, including but not limited to the following in any order or combination:
1.
2.
3.
4.
5.
Verbal warning issued by the organization.
Written warning issued by the organization.
Suspension or immediate ejection from a Pocono Summit Youth Wrestling event issued by the organization and/or league, which is authorized to issue such suspension
or ejection.
Suspension from multiple Pocono Summit Youth Wrestling events issued by the organization and/or league, which is authorized to issue such suspension.
Season suspension or multiple season suspension issued by Pocono Summit Youth Wrestling Association.
Participant signature
Date
Parents, Guardian signature
Date