801 North State Street
Jerseyville, Illinois 62052
Weigh-In: Sat, Jan 10th from 7-8PM
Sunday, Jan 11th from 6-8AM
Wrestling Begins at 9:00 AM
Fee: $15 entry fee. Registrants will be accepted until we reach 250 wrestlers. You may want to call in advance.
Frank Speidel
303 Cheney Street
Jerseyville, Illinois 62052
Fax: 618/498-5332
Home Ph: 618/639-3485
Work Ph: 618/498-5527
E-Mail: [email protected]
Name:________________________________ Card #:_______________ Phone:________________
Age:_____________ Team:__________________________________
Circle One: 6&Under 7&8 9&10 11&12 13&14
In consideration of my acceptance of this entry, intend to be legally bound hereby for myself, my heirs, executors, and administrators, waive and release the Jersey Junior Panthers Wrestling Club and Jersey School District from any and all claims or rights to damage for injuries or losses suffered by me directly or indirectly in training to or from, or competing in, or attending the Jersey Youth Wrestling Tournament.
______________________________________ _____________
Signature of Parent Date