2024-2025 Grindhouse Wrestling Club - East Monthly Registration

Step 1 of 3: Submit

Please click on monthly payment link to set up your monthly payment plan. Then fill out this registration form. Payment and Registration form MUST be complete before first practice.

Participant First Name Participant Last Name Participant Age (Please Select Appropriate Age) Grade School USA Wrestling Card Number Parent/Guardian #1 First Name Parent/Guardian #1 Last Name Parent/Guardian #1 Phone Number Parent/Guardian #1 Email Parent/Guardian #2 First Name Parent/Guardian #2 Last Name Parent Guardian #2 Phone Emergency Contact First Name Emergency Contact Last Name Emergency Contact Phone Number

Does Participant Have Any Allergies We Need to Be Aware Of? Yes No

If Yes, Please List Allergies

Does Participant Have Any Other Medical Conditions We Need to Be Aware Of Yes No

If Yes, Please List Medical Conditions Medical Insurance Company Medical Insurance Policy Holder Medical Insurance Phone Number Medical Insurance Policy Number Medical Group Insurance Number Hospital of Choice

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I have read Waiver of Liabiilty and Acknowledge

Payment Monthly Pay in 2 Installment(s)x ($75 USD/month)