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: If you would like to set up an auto debit, you can do so at practice.

I would like to:

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

Set up an auto debit (You can do so in person at practice).

Dynamite & Firecracker Black Payment Options

  • 3 Month Membership $435, or $150/ month auto debit