NAME: __________________________________ DOB__/__/__ AGE:____

CLUB/SCHOOL:_______________________________ USAW#: _____________

ADDRESS: _______________________________|_____________________________

CITY: ___________________________ ZIP CODE: __________________

PHONE: _______________ FAX: ______________ E-MAIL: ______________

CURRENT WEIGHT: ___________ GRADE: ____________________

WEIGHT CLASS YOU WANT TO WRESTLE: ____________________________

CHECK ALL THAT APPLY:

______2002 USA STATE FREESTYLE/GRECO MEDALIST PLACE:

______2002 AAU STATE FREESTYLE MEDALIST PLACE:

______2002 HUSKERLAND FOLKSTYLE MEDALIST PLACE:

______2002 CORNHUSKER STATE GAMES FR/GR/FOLK PLACE:

PAST WRESTLING EXPERIENCE AT THE STATE CHAMPIONSHIP LEVEL

(PLEASE INDICATE SANCTION/YEAR/PLACE)

PAST WRESTLING EXPERIENCE AT THE NATIONAL LEVEL

(PLEASE INDICATE SANCTION/YEAR/PLACE)

PLEASE RETURN ALL APPLICATIONS TO:

COACH PAT GARCIA

14605 "M" Street

Omaha, Nebraska 68137

WK PHONE (402) 457-7105 or HM (402) 894-1147