Alex Dieringer Camp Registration

Alex Dieringer Camp Registration
Location: Wauseon Wrestling Building

940 East Oak St, Wauseon, OH- Across the Street

Date: Sunday November 5th

Time: 10am-1:30 / 30 Minute Break at 11:30 for lunch

Age: Open to All

*** Please bring your own water bottle and snacks for break***

Questions? Contact Rudy Corpus at support@takedownnutrition.com
Athlete Name:*

First NameLast Name
Birth Date:*

MonthDayYear
Phone Number:*

Area CodePhone Number
Email Address:*
Primary Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Please provide any medical conditions or concerns you have:
If none just leave blank
Emergency Contact Information
Emergency Contact Name:*

First NameLast Name
Emergency Contact Phone Number:*

Area CodePhone Number
Relationship to You :*
ex. parent, grandparent etc...

Payment*

Registration$50.00

Enter coupon

Total $0.00