Registration Form

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Anton Talamantes Presents: The Heart and Soul Wrestling Commuter Mini-Camp
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Camp Technicians:
__________________________________________________________

T. J. Williams
NCAA National Champion 1999 & 2001 Champion 3 Time All-American State 3 Time Big 10 Champion University of Iowa’s All-time highest winning Percentage

Leroy Vega
3 Time Minnesota All-American Big Ten Champion Two time NCAA team champion 2 Time Indiana High School State Champion

Anton Talamantes
2 Time NCAA Qualifier Ohio State Michigan State Open 2 Time Indiana High School Champion 3 Time Indiana State Finals High School All-American

Michigan/Indiana Extreme Wrestling

_________________________________________________________________________________________ _

Where: Bishop Dwenger High School; Student Athletic Center (Air-conditioned) Gym
- - -- - - 1300 East Washington Center Road -- - - - - - Fort Wayne, Indiana 46825

When: Monday, through Thursday - June 7-10 from 1-4 p.m. Fee: $100.00 per camper ($75 reduced group rate of 5 +) RSVP by May 23rd.
- - - - - After May 24th: $125.00 Write checks payable to: Anton Talamantes Mail to: 1914 River Run Trail, Fort Wayne, IN 46825 Contact Number: John Bennett - (260) 486-5805 Dress: Shorts and tee-shirt, Grade Groups: Males, advancing to grades 6 - 12; for the 2010-11 school term Commemorative Tee-Shirts: distributed to campers on last day's session.

Shirt Size S_____ M______ L______ XL______ XXL________
NAME: _________________________________GRADE:_______ ADDRESS: ___________________________________________ CITY, STATE: _______________________________________ZIP: 46_________ PHONE NBR. (____)_______________________ SCHOOL____________________________________________

Permission Slip WAIVER AND PARENT PERMISSION:
I do hereby willingly and knowingly assume all rights and hazards incidental to participation including transportation to and from Bishop Dwenger High School permitting said wrestling practices, meets and tournaments to be held. I/We do hereby waive, release, absolve, indemnify and agree to hold harmless the Fort Wayne-South Bend Diocese, Bishop Dwenger High School, and any and all employees, servants or agents of said mention organizations, including but not limited to the organizers, sponsors, supervisors, participants, or John Bennett for any and all claims or damages which the participants named above might receive in said practices, meets or tournaments. I __________________________, will follow the rules or the program, and I understand that if, I am under 18 years of age, confirmation of this agreement, by my parents/guardians, is required. I/We the undersigned hereby authorize any first aid, medication, medical treatment, or surgery deemed necessary in case of emergency for _________________________, a participant in this program. I/We authorize the attending personnel to execute on my/our behalf if I/We are not immediately able to do so.

Wrestler signature: ____________________________________________________. Parent signature: ______________________________________________________.

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