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2007 Heartland Championships Registration Form |
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| Name:_________________________________________________________________________________ | |
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| Address:_______________________________________________________________________________ | |
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| City:________________________________ State:_____ Zip:_________ Phone:____________________ | |
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| Birth Date (MM/DD/YYYY):_______________ Division (6U,8U,10U,12U,14U):_____ Weight Class:_________ | |
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| Club Name:______________________________ Years of Experience (including current year):__________ | |
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| Current Year Record (W/L):_________________ Last Years Record (W/L):________________________ | |
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| Additional Information (include YEAR, TOURNAMENT, PLACE for national and state level tournaments): | |
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| _______________________________________________________________________________________ | |
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| _______________________________________________________________________________________ | |
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| _______________________________________________________________________________________ | |
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| Hold Harmless Agreement | |
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| I/We certify that ____________________________________ was born on the date stated and has my/our permission to compete in the 2007 Heartland Folkstyle Championships. I/We release Western States Wrestling (and all other clubs, agencies, and individuals assisting in the conducting of the tournament) from liability and responsibility for any accidents involving or sustained by my/our wrestler(s) or ourselves and companions during the course of the tournament (including arrival and departure). | |
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| Signature of Parent/Guardian:_____________________________________________________________ | |
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| Mail Registration To: |
Western States PRIDE Wrestling PO Box 293 Sioux City, IA 51102 |