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DSGC VI Registration Form

Name:
Mailing address:
Phone number:
E-mail:
Date of birth:
Approximate weight:
Name of school:
Name of instructor:
School phone number:
Your styles:
Do you have any previous injuries?	Yes No
If yes, please explain:
Do you have any health problems that could prevent you from participating in this event?	Yes No
If yes, please explain:
Emergency contact name:
Emergency contact phone number:
Please choose your experience level:	Beginner (under 1 year) Intermediate (over 1 year and under 3 years) Advanced (Over 3 years)
Please choose the division(s) you would like to compete in:	Gi - $35 No-Gi - $35 Both Gi and No-Gi - $60

2666 NE Stephens St    
Roseburg, Oregon, USA, 97470    
Phone: 541.514.0762    
Last Updated: 8/08/2008                                                                                                                         E-mail: dsgc@dynamicjudo.com