2012 TDM Camp Registration Form (Step 1 of 2)

All fields marked with a * are required. When finish, click "Submit" at the bottom and move onto the payment page.

Camp Attending*	Week 1: June 14 – 18 Week 2: June 21 – 25 Week 3: June 28 – July 2 Week 4: July 6 – 10 Week 5: July 12 – 16
Camper's Name*
Parents' Names*
E-Mail*
Confirm E-Mail*
Street Address*
City*
State*
Zip*
Home Phone and Cell Phone*
Age at Camp*
Estimated Weight*
Estimated Height*
T-Shirt Size*	Youth S Youth M Youth L Adult S Adult M Adult L Adult XL Adult XXL
Health Insurance Company*
Policy Number
How did you hear about our camp?
Please list the wrestler's major accomplishments
Comments
Medical Release* By typing my name in the box to the right, I agree that my son/daughter has been examined by a physician in the last year and is in good health. I hereby authorize the Takedown Machine Staff and Purler Wrestling, Inc. to act for me, according to its best judgment in any medical emergency, and I herby waive and release Purler Wrestling, Inc. from any liability for injuries or illness incurred by my son/daughter while attending camp. All information I have provided on this application is true and correct.
Will your child need airport transportation* If yes, please contact Jackie at jackie@purlerwrestling.com for scheduling and pricing	Yes No
Type the following: For security purposes, please type the letters in the image.