Dakota Wrestling Club
2009/10 Wrestler Registration Form
Wrestlers Name:
Date of Birth:
Address:
City:
State:
Zip:
Home Phone:
School Attending:
Age as of Dec 31, 2010:
Weight:
Years of Wrestling Experience:
Location of Previous Wrestling Experience:
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Registration Fee & Uniform:
None
Youth Small
Youth Medium
Youth Large
Youth XL
Adult Small
Adult Medium
Adult Large
Adult X Large
Registration, T-Shirt & Singlet
$70
T-Shirt Size
All fees will be collected at the parents meeting in November.
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Parent/Guardian 1:
Cell #:
Parent/Guardian 2:
Cell #:
Email 2:
Email 1:
Wrestler's Primary Health Insurance Coverage Company:
Primary Coverage Contract Number:
Please list any allergies/medical problems, including any requiring maintenance medication(s). (i.e.
Diabetic, Asthma, Seizure Disorder, etc....)
Yes
No
I (we) do hereby release the Dakota Wrestling Club and it's membership of any
responsibility for injury or illness incurred during practice or participation in a
wrestling event.
Yes
No
I understand and acknowledge that as a parent of guardian of a Dakota Wrestling
Club wrestler I am required to work at any tournaments the club hosts and assist in
the club's league commitments at the regional and state tournaments.
Dakota Wrestling Club: 50762 Nagy Ct, Macomb, Mi 48044
Dakota Wrestling Club
