Director Of Wrestling
PRODIGY FS/GR CLUB REGISTRATION FORM
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Name (print):
School:
Willie Wineberg
4 Time Division I State Wrestling Champion (1991-1994)–Fairfield High School
2 Time NCAA National Qualifier–Purdue University
Head Wrestling Coach (1999-2014)­–Miamisburg High School
Director of Wrestling–Prodigy Wrestling Academy
School is a Member of the Partner School Program
PRODIGY Freestyle and
Greco Club Coaches
T-Shirt Size: YS YM YL AS AM AL XL XXL
*Must register by March 31st to receive a club t-shirt.
Drop ins do NOT receive a club t-shirt.
Willie Wineberg–AAU, Cadet, and Espoir Freestyle National Champion
I have a Prodigy Waiver Form on file from this season
*Participants at all sites must have a completed waiver on file at
Prodigy from this season. If not, Waivers can be found
at www.prodigywrestlingacademy.com
Registration:
Freestyle Club
$______ / $100
Greco Club
$______/ $60
*USA Wrestling Card required at both North Sites
ALL WRESTLERS ATTENDING THE NORTH SITES MUST TURN IN A
COPY OF THEIR CURRENT USA WRESTLING COMPETITOR’S CARD
BEFORE BEING ALLOWED TO PARTICIPATE IN PRACTICE.
Cards are available online at www.usawrestling-ohio.org
(Visa or Mastercard) for $40 (all age division).
If you already have a Folkstyle card, there is an additional $25 fee
to wrestle Freestyle/Greco.
Gary Wise–Beavercreek Head Coach, Raider Wrestling Club Founder/Director
Jim lehman—–Lakota East High School, Head USA-Ohio Freestyle Coach
Frank Baxter—Fairmont HS
Fred Boulton—Springboro HS
Jeremy Clingner—Beavercreek HS
Mark Gerhard—Carroll HS
Steve Harris— Beavercreek HS
Mark Peck—Butler HS
Kelly Stevens—Butler HS
Dennis Webb—Beavercreek HS
John Berry—Prodigy Coach,
Shawn Thomas—Prodigy Coach
Jason Ashworth—Carroll High School
Tim kelly—Greco Roman Coach, Reading High School
.....and many more
March 21—May 26
Spring
FOR NORTH SITE WRESTLERS ONLY
I have a current USA Wrestling Card.
USA Card is attached.
USA Wrestling Card #:
Make checks payable to: Prodigy Wrestling Academy
Contact Information:
Email: [email protected]
Or call: 937-371-0432
Visit us at: www.prodigywrestlingacademy.com
*Prodigy has a no refund policy for all wrestling programs.
visit us at: www.prodigywrestlingacademy.com
South Location
Prodigy Training Center
235 S. Pioneer Blvd.,
Springboro, Ohio 45066
North Locations
Beavercreek High school
2660 Dayton Xenia Rd,
Dayton, Ohio 45434
Vandalia Butler High School
600 South Dixie Drive,
Vandalia, Ohio 45377
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Fre co Rom
Gre ining
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March 21—May 26
The Next Level in Training
Four nights a week at three
convenient locations and
one low price
Freestyle Club
Cost: $100 Full membership
$10 Drop in Fee
Greco-Roman Club
Cost: $60 Full membership
$10 Drop in Fee
Weekly Practice Schedule
Monday @ Prodigy Training Center
Greco Club–5:30–6:30 pm
Freestyle Club–6:30-8:00 pm
Tuesday @ Beavercreek High School
Freestyle club– 6:30-8:00 pm
Wednesday @ Prodigy Training Center
Greco Club–5:30–6:30 pm
Freestyle– 6:30-8:00 pm
Thursday @ Vandalia Butler High School Freestyle– 6:30-8:00 pm
USA Wrestling Medical Consent Form
Name of Primary Insurance Company
Parent or guardian of minor must read and
complete the following:
Policy#
Address
Without this signed authorization from the parent/guardian, hospitals in many states
are obligated by law to delay treatment of a contestant’s injury or illness until the parents can be reached by telephone and their permission granted to begin treatment. Such
a delay can prove unnecessarily painful and even dangerous to the athlete, particularly if
the parents cannot be reached immediately. To avoid such delays, the parent/guardian
should check one of the options below and endorse the selection with his/her signature.
Family Doctor
CHECK ONE:
Phone
If my child needs medical attention, it is my wish that I be contacted before any
medical procedures are begun, unless immediate medical treatment is necessary to
save my child’s life or prevent permanent injury, in which event I authorize all necessary
treatment.
Presently on any medication?
Drug Sensititves or allergies
If my child, named above, needs medical treatment during this event,it is
my wish that the nescessary treatment be initiated while efforts are being made to
contact me. So that treatment of my child will not be delayed, I consent to any medical
procedures that the physician believes my child needs, on the understanding that efforts
will continue to be made to reach me. I accept responsibility for all costs related to such
treatment.
Special Medical Conditions
Adult athletes hereby authorize and consent to emergency medical treatment.
Exceptions—List any medical procedures that you do not want performed unless specific
approval is received.
If Yes, please list medication(s)
Please Indicate Another Person to Call
In Case of Emergency
PARTICIPANT ACKNOWLEDGES THAT PARTICIPANT HAS HAD SUFFICIENT OPPORTUNITY TO REVIEW
THE PROVISIONS OF THIS DOCUMENT AND UNDERSTANDS ITS PURPOSE, MEANING AND INTENT.
Name
PRINT NAME OF PARTICIPANT
Phone
SIGNATURE OF PARTICIPANT
DATE
SIGNATURE OF PARENT OR GUARDIAN
DATE