CLINICIANS
Return Forms To: Coach Gary Keener 31 North Greenview Road Schuylkill Haven, PA 17972
[email protected] Josh Kindig & Corey Keener Combined Career Wins 362 Pins 189 State Titles 4 State Medals 7 Regional Titles 6 District Titles 6 League Titles 8 Freestyle State Titles 18 Fargo Stop Signs 11
Club Mission Our mission is to provide our athletes with a unique wrestling experience, custom built to their needs and goals.
Josh Kindig Assistant Coach at
SIGN UP Name Address
University of North Carolina
Location: Pottsville HS Boys Gym
Age
Hours
Grade Years of Experience
09:30-11:30 AM 12:30-02:30 PM
School Parent or Guardian Name
FEES
Home Phone Cell Phone
Non-Pottsville students $15.00 Pottsville Students $10.00 Price Includes t-shirt
Email Insurance Carrier Insurance ID Number Shirt Size Circle
Return Forms To: Coach Gary Keener 31 North Greenview Road Schuylkill Haven, PA 17972
[email protected] Corey Keener Central Michigan University Wrestling Team
YS,YM,YL, S,M, L, XL
PARENTS PLEASE READ AND SIGN I hereby authorize the Tide Mat Club Staff to act for me according to their best judgment in any emergency requiring medical attention for my child. I hereby waive and release the Tide Mat Club from any and all liability for any injuries and illnesses incurred during the clinic. I hereby warrant that my child is in good physical condition and is capable of participating in your program.
Signature: _______________________________