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Heartland Havoc Team Duals Registration Form
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Categories
*
Register a Team ($100 deposit)
- $100.00
NOTE:
As TEAM CONTACT/COACH, enter your personal info, your Team Name and Team Access Code, and pay the entry fee (if applicable). As TEAM CONTACT/COACH, you are registered. However, each GROUP MEMBER must also register for the event.
A link for the TEAM MEMBERS to register will be included in your registration confirmation email for you to forward to your TEAM. They should select the TEAM MEMBER registration category, select your team name, and enter the access code you have designated.
Join a Team
Setup Team Information
Team Name
*
Team Access Code
*
This is the access code your teammates will need to enter to join your team.
This is NOT a password or discount code. It is an access code for your team that you come up with.
We will send you an email with instructions and a member registration link that can be forwarded to your team members.
Team Information
Division
*
-- select one --
Boys
Girls
Wrestlers
(Submit up to
15
members)
*
new team member
First Name
Last Name
Email Address
Gender
Date of Birth
Weight Class (in lbs)
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Coach Information
Contact Email
*
Coach First Name
*
Coach Last Name
*
Coach Birthdate
*
- month -
Jan
Feb
Mar
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- day -
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- year -
2024
2023
2022
2021
2020
2019
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2012
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1919
Coach Gender
*
Male
Female
Country
*
-- select country --
Canada
International
United States
Street Address (w/Apt#)
*
City
*
State
*
-- select state --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Col.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
-- select state --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Col.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
-- select province --
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Zip Code
*
Phone
*
Waiver
*
I have read and agreed to the TERMS
*
Click here to view the TERMS
.
Is the participant 18 or older?
*
18 or older
Under 18
Parent or Legal Guardian’s Signature - By providing your electronic signature you agree that you have the authority to register these participants and agree to the waiver(s) for them as their parent or legal guardian.
If registering a child under 18, you are consenting to the collection of the child's information that you are providing for the purposes of registration.
Parent's signature
Payment Details
Discount or Tracking Code
Apply
Do not COPY & PASTE the code, please type it into this field.
Price
$
Discount (-)
$
Total
no handling
$
Processing
$
Total Owed
$
Payment Method
The payment and credit card section is not visible because there is nothing owed or form fields have not been fully completed.
Visa
Mastercard
Cardholder First Name
Cardholder Last Name
Cardholder Address
Cardholder Country
United States
Argentina
Australia
Bermuda
Brazil
Canada
Czech Republic
Columbia
Costa Rica
Czech Republic
France
Germany
Japan
Ireland
Italy
Mexico
Netherlands
Norway
Puerto Rico
Singapore
Spain
Sweden
Trinidad and Tobago
United Kingdom
City, State, Zipcode
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Credit Card #
Exp. Date
MM
01
02
03
04
05
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/
YY
23
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33
CVV Code
Your payment is encrypted and 100% secure.
Payable To:
Address:
click the "submit" button to submit your order then send a check to (or pay in person at) the address above.
1. Venmo the total amount to the Phone #:
2. Make sure you enter the code,
68694
in "What's it for".
3. Click the "pay now" button.
Enter a Check Number
Enter a Check Amount
Send email receipt to the participant
Purchase
Purchase
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