Mail check & this form to:

Paul Powis

13001 Walton Bluff Circle

Midlothian, VA 23114

PLEASE NOTE YOU WILL STILL BE REQUIRED TO COMPLETE MEDICAL

RELEASE FORMS AT ONE OF THE MANDATORY REGISTRATION

MEETINGS ON MON, 10/27/08, TUE, 10/29/08, AND THU, 10/30/08.

Wrestler #1 Information:

First Name:____________________   Last Name:_______________________

Approx. Weight:___________  T-shirt Size:  Adult:_______ or Youth:_______

Name of School Attending:________________________________________

Elementary School Boundary in Which the Wrestler Lives:________________

Current Grade:________                     Date of Birth:____/____/______

                                                                                           mm    dd       yyyy

Age as of 12/31/2009:___________      (it is not a typo....need age as of 12/31/09)

Most recent year your child(ren) was a NCYW team member:________

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If you have a 2nd Wrestler from your family: 

Wrestler #2 Information:

First Name:_____________________   Last Name:_____________________

Approx. Weight:___________  T-shirt Size:  Adult:______ or Youth:______

Name of School Attending:_______________________________________

Current Grade:___________                   Date of Birth:____/____/______

                                                                                         mm    dd       yyyy

Age as of 12/31/2008:___________      (it is not a typo...need age as of 12/31/09)                     

Most recent year your child(ren) was a NCYW team member: ________

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Parent/Guardian Info:

Mom First Name:___________________ Last Name:__________________________

Dad First Name:____________________ Last Name:__________________________

Child's Residential Address:______________________________________________

City:______________________    State:________  Zip:_______________

E-mail is our primary method of contact.

1st E-mail address:__________________________________________________

2nd E-mail address:_________________________________________________

Home phone: ____________________  Mom Cell phone: _____________________

Dad Cell Phone:______________________