SAMURAI WRESTLING CLUB
* Freestyle * Greco-Roman * Folkstyle *
An Officially-Chartered USA Wrestling Club
Held at The University of Mount Union Wrestling Room
McPherson Academic and Athletic Complex
1972 Clark Avenue, Alliance, Ohio 44601
MONDAYS & WEDNESDAYS
6:00PM - 8:00PM
SPRING SESSION: MARCH 14 - MAY 18
**************************************************
REGISTRATION
Monday, March 14 from 5:15-6:15 with practice to follow!
“The amount of strength that you have depends upon the training and practice
that you have put into your art.”
-Miyamoto Musashi-
CLUB FOCUS
Samurai translates as “one who serves.” Our club focus is to serve those wrestling warriors in our area who are willing to put forth
the extra efforts necessary to master their art and work to become champions by providing them opportunities to develop through
instruction, practice, and competition. Samurai Warriors lived under a strict code of honor known as Bushido or “The Way of the
Warrior.” We will also stress a “code” of high ethical standards in our approach to work, competition, and life beyond the mats.
PROGRAM
This Wrestling is designed for the serious wrestlers from middle-school through the collegiate level. We are an officially-chartered
club under USA Wrestling and will conduct our operations to meet their standards. We will focus our instruction on teaching the
fundamentals as well as advanced techniques and strategies in both Olympic Styles of wrestling (Freestyle & Greco-Roman), as well
as collegiate or folkstyle wrestling. Along with our staff, it is our goal to bring in top-notch clinicians throughout the program.
DIRECTOR & COACHING STAFF
Director & Coach Jeff Kullman has been the USA-Ohio Wrestling Cadet National Freestyle and Greco-Roman Director for over
16 years. He was the 2011 USA-Wrestling National Coaches Education Program Instructor of the Year. Coach Kullman has over
30 years of coaching experience; was the head coach of Minerva H.S. for 22 years, and has served as an assistant coach for Massillon
Perry H.S. and Minerva H.S. In addition, he is a Certified Personal Trainer and Sports Performance Enhancement Specialist through
The National Academy of Sports Medicine (NASM). He will be joined by several local high school and USA-Ohio Wrestling Cadet &
Junior Staff Coaches along with the University of Mount Union Wrestling Coaches.
CLUB MEMBERSHIP & FEES
CLUB FEE: $95.00
PLUS USA CARD:
Option A) $40.00 Competitor’s Card - Covers secondary sports accident insurance and allows you to
compete in all USA Wrestling sponsored state, regional, and national freestyle & greco tournaments.
Option B) $15.00 Limited Folkstyle Card - Covers secondary sports accident insurance and allows you to
compete in USA Wrestling sponsored state, regional, and national folkstyle tournaments.
* Discounts available for members from the same family. Contact Coach Kullman.
Club Fee includes all practices, instruction, and club t-shirt. In addition, All WRESTLERS & COACHES MUST have a CURRENT
(2016) USA WRESTLING CARD. It is preferred that you purchase your card prior to the start of club practices. If you cannot, you may
order your card at our registration / first practice. To purchase USA Card go to www.usawmembership.org or www.themat.com and
follow the membership cues. Register under Samurai Wrestling Club.
Complete the following Samurai Wrestling Club Registration and USA Release and Waiver of Liability Form
attached in this packet. All checks can be made out to “Samurai Wrestling Club LLC”
For more information, please contact Jeff Kullman @ 330-704-5588 or via email @ [email protected]
REGISTRATION CHECK LIST:
[] Club Fee
[] USA Wrestlers Card (Purchased prior to club practice or registration.)
[] Completed Samurai Wrestling Club Registration Form - (Attached)
[] Completed and signed by parent USA Wrestling Waiver of Liability Form - (Attached)
- 2016 SAMURAI WRESTLING CLUB REGISTRATION
Wrestler’s Full Name: __________________________________________________________________________
USA Wrestling Card #: ___________________________ Age: _______ Date of Birth: _______________________
USA Wrestling Age Division: (Check One)
[] Junior ................
Born 9/1/1996 or after, plus enrolled in grades 9 -12
[] Cadet ................
Born 2000 - 2001
[] School Boy .......
Born 2002 - 2003
[] Novice ..............
Born 2004 - 2005
School District Attending: _________________________________________________________ Grade: _________
Home Street Address: ____________________________________________________________________________
City: _________________________________________________________ Zip Code: ________________________
Home Phone Number: ___________________________ Email Address: ____________________________________
Participant’s Cell Phone Number: ___________________________________________________________________
Father’s Full Name: ______________________________________________________________________________
Father’s Home Phone (if different than above) _________________________________________________________
Father’s Work #: _________________________________ Father’s Cell #: _________________________________
Mother’s Full Name: _____________________________________________________________________________
Mother’s Home Phone (if different than above) ________________________________________________________
Mother’s Work #: _________________________________ Mother’s Cell #: ________________________________
Other Emergency Phone Number: ___________________________ Contact Person: _________________________
Participant’s T-Shirt Size: (Included in fee)
Check One:
[] S
[] M
[] L
[] XL [] 2XL
Do parent’s/guardians carry hospitalization insurance? YES NO (circle one)
NOTE: This club does not carry medical insurance for participants. The participant’s parent and/or legal guardians assume all
responsibility for said insurance. Purchasing a USA Wrestling Competitor’s/Coach’s Card does insure participants with a secondary
sports accident insurance.
Membership Level:
[] Club Fee: $95.00
[] Carries Current 2016 USA Card - No Charge.
[] $40.00 Competitors Card -or[] $15.00 Limited Folkstyle Card
Total Cost: __________________
Make Checks Payable to “Samurai Wrestling Club LLC”
*** MUST COMPLETE USA WRESTLING RELEASE AND WAIVER OF LIABILITY AGREEMENT ON BACK OF THIS PAGE ***
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT
WITH PARENTAL CONSENT (“AGREEMENT”)
IN CONSIDERATION of being permitted to participate in any way in any event (“Activity”) at any time during the current
calendar year I, for myself, my personal representatives, assigns, heirs, and next of kin:
1. ACKNOWLEDGE, agree, and represent that I understand the nature of the Activity and that I am qualified, in good
health, and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I
believe the conditions to be unsafe, I will immediately discontinue further participation in the Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY INJURY, INCLUDING
PERMANENT DISABILITY, PARALYSIS, AND DEATH (“Risks”); (b) these Risks and dangers may be caused by my own actions
or inactions, the actions or inactions of others participating in the Activity, the conditions in which the Activity takes
place, or THE NEGLIGENCE OF THE “RELEASEES” NAMED BELOW; (c) there may be OTHER RISKS or SOCIAL AND ECONOMIC
LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS
AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation, or that of the minor,
in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their administrators,
directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel, sponsors,
advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be considered
one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON MY ACCOUNT CAUSED,
OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, INCLUDING
NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if, despite this RELEASE AND WAIVER OF LIABILITY,
ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or anyone on my behalf, makes a claim against any of the
Releasees, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES from any litigation expenses, attorney
fees, loss, liability, damage, or cost which may be incurred as the result of such claim.
I ACKNOWLEDGE THAT I AM AGE 18 OR OLDER, HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS,
UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL
LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD
TO BE INVALID, THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINTED NAME OF PARTICIPANT:
PARTICIPANT’S SIGNATURE:
ADDRESS:
(Street)
PHONE:
(City)
(State)
(Zip)
DATE:
MINOR RELEASE: (must be completed by Parent/Guardian for any participant under the age of 18)
AND I, THE MINOR’S PARENT AND/OR LEGAL GUARDIAN, UNDERSTAND THE NATURE OF THE ACTIVITY AND THE MINOR’S
EXPERIENCE AND CAPABILITIES AND BELIEVE THE MINOR TO BE QUALIFIED, IN GOOD HEALTH, AND IN PROPER PHYSICAL
CONDITION TO PARTICIPATE IN SUCH ACTIVITY. I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO
INDEMNIFY AND SAVE AND HOLD HARMLESS EACH OF THE RELEASEES FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR
DAMAGES ON THE MINOR’S ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF
THE “RELEASEES” OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS AND FURTHER AGREE THAT IF, DESPITE THIS
RELEASE, I, THE MINOR, OR ANYONE ON THE MINOR’S BEHALF MAKES A CLAIM AGAINST ANY OF THE RELEASEES NAMED
ABOVE, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION EXPENSES,
ATTORNEY FEES, LOSS LIABILITY, DAMAGE, OR ANY COST THAT MAY OCCUR AS A RESULT OF ANY SUCH CLAIM.
PRINTED NAME OF PARENT/GUARDIAN:
PARENT/GUARDIAN SIGNATURE ( if participant is under the age of 18):
ADDRESS:
PHONE:
(Street)
(City)
DATE:
(State)
(Zip)