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Nava/Breffle Wrestling 2017-2018 Online Registration Form

(you can use the tab key to quickly move to the next field)
Wrestler's First Name *
Your answer
Wrestler's Last Name: *
Your answer
Street Address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip: *
Your answer
Wreslter's DOB: *
Wrestlers Birthdate (00/00/00)
MM
/
DD
/
YYYY
Wrestler's Approximate Weight: *
(number only, this will help us to match practice partners and to gauge the size of singlet)
Your answer
Wrester's Approximate Height: *
(inches only, this will help us match practice partners and to gauge the size needed for singlet)
Your answer
School: *
Your answer
Grade: *
(wrestler's grade during the 2016-2017 Season)
Required
Years of Wrestling Experience: *
Required
T-Shirt Size: *
(wrestler's t-shirt size)
Required
Wrestler's USA Card #:
(you can register without the card, but your wrestler will not be able to practice without a valid card - bring to the first day of your wrestler's practice)
Your answer
Parent /Guardian Information:
Mother's (or guardian's) First Name:
Your answer
Mother's (or guardian's) Last Name:
Your answer
Street Address:
(if same as wrestler's - type same)
Your answer
City:
(leave blank if same as wrestler's)
Your answer
State:
(leave blank if same as wrestler's)
Your answer
Zip:
(leave blank if same as wrestler's)
Your answer
Mother's (guardian's) Home Phone:
Your answer
Mother's (guardian's) Cell Phone:
Your answer
Mother's (guardian's) Email Address:
Your answer
Father's (guardian's) First Name:
Your answer
Father's (guardian's) Last Name:
Your answer
Street Address:
(type same if the same as wrestler's)
Your answer
City:
(leave blank if same as wrestler's)
Your answer
State:
(leave blank if the same as wrestler's)
Your answer
Zip:
(leave blank if the same as wrestler's)
Your answer
Father's (guardian's) Home Phone:
Your answer
Father's (guardian's) Cell Phone:
Your answer
Father's (guardian's) Email Address:
Your answer
Medical Information:
By completing the below you have also not authorized the Nava/Breffle Wrestling Club or any representative of the program to medically treat or authorize medical treatment of your minor wrestler(s) unless you sign the liability/waiver form.
Wrestler's Physician: *
Your answer
Physician's Phone Number: *
Your answer
Last Tetanus Booster: *
Your answer
Is there any additional medical information that we need to know about your child?
(asthma, allergies, etc....)
Your answer
Emergency Contact:
Emergency Contact Name: *
Your answer
Emergency Contact Number: *
Your answer
Relationship to Wrestler: *
Your answer
Thank you !!
Thank you for completing this form. Registration is not complete until payment has been received. Please print out, sign and bring the Liability and Waiver form, a copy of your wrestler's USA Card and payment to your wrestler's first practice. You can contact us via email: navabrefflewrestlingclub@gmail.com if you have additional questions!
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