Name___________________________Address_________________________City ____________________________State____ Zip __________PhoneNumber_________________________Grade ____________School__________________________E-mailAddress_________________________Coach’sName___________________________
Emergency Contact________________________________EmergencyPhone___________________________
Parental hold harmless statement
I agree not to hold Barre Wrestling Club, Spaulding HighSchool, BYSA, Barre Civic Center, or anyone involvedwith the Central Vermont Summer Wrestling Clinicresponsible or liable for any accident, medical, dental, orany other expense incurred as a result of my child’sparticipation at the clinic. In case of injury, you have mypermission to administer first aid or take him/her to adoctor or hospital to be treated.
________________________________
Signature of parent or guardian date
Please include your
Check/Money
Order
made out toDarren O’Meara (
cash
will be accepted) – sorry, norefunds.
Featuring 2008 US Olympian and1999 NCAA Champion
DOUG SCHWAB
July 28
th
& 29
th
Spaulding High School155 Ayers St.Barre, Vermont 05641
B a r r e W r e s t l i n g C l u b 9 9 U S R T 3 0 2 W e s t T o p s h a m , V T 0 5 0 8 6
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