Wrestle Like A Champ Camp!
Camp Staff: Curtis Chenoweth 2006 NAIA National Champion, 2X All American
Deadline – June 15th
Please mail your entry to:
PO Box 61
Clearwater, KS 67026
Or email: dad2greatboys@gmail.com
If emailing you must attach the filled out form
& bring signed copy the day of camp!
Class is limited to 30 participants!
Joe Johnson 2X NJCAA All American
Guy Johnson Clearwater High School Head Wrestling Coach
Michael Pelz Clearwater High School Assistant Wrestling Coach
Camp will touch all three different aspects of wrestling…takedowns, top control and bottom wrestling!
Please join us for a great day of education and fun!
When: Saturday June 18, 2011
Where: Clearwater High School Wrestling Room
1201 East Ross, Clearwater KS 67026
Cost: $25 with USAW Card
$62 without USAW Card
Registration begins at 9:00am
First Session: 9:30am – 11:30am
Lunch Break: 11:30am – 12:30pm
Second Session: 12:30pm – 2:30pm
Third Session: 3:00pm – 4:30pm
Participant Name:__________________________________ Age:______ Weight:______lbs
DOB:____/____/_______ USAW Card #_________________
Address ______________________ City/State/Zip________________________________
Emergency phone Number: (____)_____-______ Email_______________@______._____
Medical Insurance Co & Policy # ______________________________________________
Parent Name/Emergency Contact: _____________________________________________
Waiver: My son/daughter has been examined by a physician in the last year and is in good health. I hereby
authorize the Clinic Staff to act for me, according to its best judgment in any medical emergency and I hereby
waive and release said camp from any liability for injuries or illness incurred by my son/daughter while
attending camp. All information I have provided on this application is accurate.
PARENT SIGNATURE:_______________________________ DATE: _____/_____/_______
All participants must be picked up no later than 5:00pm
All questions and inquiries should be directed to:
Clint Luckner at (620) 584-4446 or (316) 650-9393 or dad2greatboys@gmail.com
A big THANK YOU to Clearwater High School for the use of their facility and to Clearwater
Youth Wrestling Club for providing lunch for the wrestlers, coaches and staff!
