AREA 1 CHAMPIONSHIP – FAYETTE COUNTY QUALIFIER

PJWC CHAIRPERSON Larry Newcomer RD#1 Box472 Scottdale, PA 15683 Phone: 724‐887‐5496 E‐Mail: [email protected] SECRETARY‐TREASURER Lloyd Rhoades, Jr. 1138 N. Eagle Valley Road Howard, PA 16841 Phone: 814‐355‐1776 E‐Mail: [email protected] AREA 1 CHAIRMAN David Tims 1426 Piedmont Road Somerset, PA 15501 Phone: 814‐443‐1258 E‐mail [email protected] COOPERATION IS THE THEME OPERATION IS THE TOOL AND DEVELOPMENT OF YOUNG PEOPLE IS AREA 1 ALTERNATE Robert W. Williams 9 South Penn Street Connellsville, Pa 15425 Phone: 724‐963‐8223 E‐Mail: [email protected] AREA 1 CHAMPIONSHIP – FAYETTE COUNTY QUALIFIER (FAYETTE COUNTY RESIDENTS ONLY) Date: Weigh‐Ins: Wrestling Time: Seeding Meeting: Awards: Wednesday March 4 2015 at Laurel Highlands High School 4:30 pm to 5:30 pm 6:00 pm Wednesday Feb 25, 2015 at 7:00 p.m. at Laurel Highlands High School 1st, 2nd, 3rd place metals PIAA WRESTLING RULES MODIFIED BY PJWC ALL TOURNAMENTS FROM QUALIFIERS TO STATES WILL BE DOUBLE ELIMINATION **NOTE** COPY OF BIRTH CERTIFICATES MUST ACCOMPANY ENTRY FORM. Age: Age effective date is December 31, 2014 Entries: All Entries need to be brought by coach to seeding meeting (Feb. 25, 2015) Entry Fee: $25.00– No entries will be accepted without entry fee and copy of birth certificate!! MAKE ALL CHECKS PAYABLE TO: Laurel Highlands Wrestling MORE INFO CONTACT: Dave Tims or Robert Williams (see top of page for phone number) Bring form to seeding meeting NAME AGE BIRTHDATE ADDRESS PHONE STREET CITY COACH SCHOOL DISTRICT STATE COUNTY CIRCLE THE WEIGHT CLASS WITHIN THE DIVISION YOU WISH TO WRESTLE. CIRCLE ONLY ONE. Division Weight Classes 8 and Under: 45, 50, 55, 60, 65, 75, 90, 110 MAX 10 and Under: 55, 60, 65, 70, 75, 80, 85, 90, 95, 105, 120, 150 MAX. 11 and 12: 65, 70, 75, 80, 85, 90, 95, 100, 105, 115, 125, 135, 145, 160, 200 MAX KINDLY ENTER ME IN THE ABOVE WRESTLING TOURNAMENTS. IN CONSIDERATION OF YOUR ACCEPTANCE OF THIS ENTRY, I INTENDING TO BE LEGALLY BOUND HERE‐BY FOR MYSELF, MY HEIRS, AND ASSIGNS, WAIVE ANY AND ALL CLAIMS TO DAMAGES WHICH I HAVE AGAINST THE PENNSYLVANIA JUNIOR WRESTLING COMMITTEE, THE SPONSORS OF THE QUALIFYING TOURNAMENTS, AND THE COMMITTEE IN CHARGE. I AM A RESIDENT OF THE STATE OF PA. PARENT/GUARDIAN CONTESTANT RELEASE AND WAIVER OF LIABILITY AGREEMENT & PARTICIPANT CODE OF CONDUCT
I,
, acknowledge that I have voluntarily applied to participate in the
(Entrants full name)
Pennsylvania Junior Wrestling (PJW) Tournament. I am aware that these activities may be hazardous and that I could
be seriously injured. I am voluntarily participating with knowledge of the danger involved, and agree to assume any
and all risks of bodily injury, or death, whether those risks are known or unknown.
I verify this statement by placing my initials here: ___ ___ Parent or Guardian’s initials: ___ _____
As consideration for being permitted by PJW, and any owner, administrator, tournament director, chairperson of the
premises holding any of the events, to participate in these activities and use the premises and facilities, I forever
release PJW or any Lessor or any PJW affiliated organization, and their respective directors, officers, employees,
volunteers, agents, contractors, and representatives (collectively “Releasees”) from any and all actions, claims, or
demands that I, my assignees, heirs, distributees, guardians, next of kin, spouse and legal representatives now have, or
may have in the future, for injury, death, or property damage, related to (i) my participation in these activities, (ii) the
negligence or other acts, whether directly connected to these activities or not, and however caused, by any Releasee,
or(iii) the condition of the premises where these activities occur, whether or not I am then participating in the
activities. I also agree that I, my assignees, heirs, distributees, guardians, next of kin, spouse and legal representatives
will not make a claim against, sue, or attach the property of any Releasee in connection with any of the matters covered
by the foregoing release.
I have carefully read this agreement and fully understand its contents. I am aware this is a release of liability and a
contract between myself and PJW, and the lessors, and sign it of my own free will. When Signed by Parent or
Guardian: I recognize the dangers of the activities and the significance of this Release and Waiver were explained to
the Participant and that the Participant understood them, or I, as parent of the Participant, understand them.
While participating in PJW activities, the Participant will be supervised by _________________________.
(Coach or Parent’s name)
I understand the Tournament Director, under the guidance of the PJW rules and administration, may withdraw our
son/daughter from any Tournament if he/she is involved in behavior or activity deemed to be detrimental to the health,
safety or welfare of other participants, spectators, tournament staff, or tournament sites; or if involved in actions
considered to be detrimental to the goals and objectives of PJW or in violation of the PJW Code of Conduct. We have
read and agree with the tournament rules as listed on the information page.
_____________________________________
Parent/ Guardian Signature
_______________________
Date Signed
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Contestant Signature
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Date Signed