Dallas Dynamite Registration Form

Choose a Program:

Contact INFO

Student's Name: First

Last:

Birth Date (mm/dd/yr):

Mother's Name:

Father's Name:

Home Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Insurance Company:

Contact Email:

BILLING INFO

Billing Contact: First

Last :

Home Phone:

Relation to
Student:

Is the billing address the same as the home address above ?:

Billing Address:

City:

State:

Zip Code:

EMERGENCY CONTACTs

Emergency
Contact 1:

Relation to Student:

Home Phone:

Work Phone:

Cell Phone:

Emergency
Contact 2:

Relation to Student:

Home Phone:

Work Phone:

Cell Phone:

STUDENT Wrestling Background

Age:

Current Weight:

Years in wrestling:

School Grade:

School:

Allergies:

Other Physical Conditions:

Current Season Folkstyle Record:

Wins:

Losses:

Current Competitive Weight Class:

Last Season's Post-Season Finishes:

District:

Regions:

State:

Please list any other past significant wrestling accomplishments and year at the State, Regionals or National level (Folkstyle, freestyle, and greco)

How did you hear about Dallas Dyanmite?

Comments:

Payment Options

To the right is a list of the various payment options for reference purposes.

Option 1: If you would like to pay up front for several months at a time, you can do so online after you submit this form.
Option 2: Pay by check or cash at practice. Note: your spot will not be guaranteed until payment has been received.

I would like to:

Pay up front (You can do so after you submit this form).

Pay by Cash at Practice.

Dynamite High School Preseason Training Camp: $275
Firecracker Preseason Training Camp: $275
Fundamentals of Wrestling Camp: $175
Adult Grappling: $100