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Bethel Allstars Wrestling PCJWL Season Registration
**Please complete one form per wrestler**

Cost per wrestler
PCJWL Season: $125.00
$25.00 refundable volunteer deposit
Discounts available for multi wrestlers (only available within individual families)
*****NEW WRESTLERS***** Must Bring COPY of Wrestlers Birth Certificate turned in First Week of Practice

*
USA Card Number
Your answer
FIRST NAME *
Your answer
LAST NAME *
Your answer
DATE OF BIRTH *
MM
/
DD
/
YYYY
GRADE
Your answer
ADDRESS
In order to run a successful season we need volunteers. Please let us know how you would be willing to help *
ADDRESS *
Your answer
CITY/STATE/ZIP *
Your answer
PARENT / GUARDIAN INFORMATION #1
PARENT/ GUARDIAN NAME *
Your answer
CONTACT NUMBER *
Your answer
EMAIL *
Your answer
WOULD YOU LIKE EMAIL OR TEXT REMINDER *
PARENT/GUARDIAN INFORMATION #2
PARENT/ GUARDIAN NAME
Your answer
CONTACT NUMBER
Your answer
EMAIL
Your answer
WOULD YOU LIKE EMAIL OR TEXT REMINDER
EMERGENCY CONTACT ( OTHER THAN PARENT
NAME *
Your answer
PHONE NUMBER *
Your answer
DOCTORS NAME
Your answer
PHONE NUMBER
Your answer
ALLERGIES? *
Your answer
DRUG SENSITIVITES: *
DESCRIBE IF YES
Your answer
Is child presently on medication?
List Medication
Your answer
Preferred Hospital
Your answer
Name of Insurance/group number *
Your answer
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