Team Charlotte Premier Track Club

Team Charlotte Premier Track Club Team Charlotte is a Non Profit Corporation formed as a community – based, collegiate-oriented organization that will aim to attract young adults ages 5-19 years old Team Charlotte primary focus will be to create career opportunities that will stem from various horizons such as: Educational, Development, and athletic training, geographic, coaching and mentoring, computer technology, job training, and behavior intervention with the utilization of social skills. Registration and uniform fees are nonrefundable.

APPLICANT INFORMATION

Last Name:

First

Street Address: City:

APT #

State

Phone:

ZIP

E-mail

EDUCATION

School:

Current Grade:

State:

Extracurricular Activities:

Subject(s) needing assistance Name: City:

State:

Relationship:

Doctor’s Name:

Parent/Legal Guardian First: Parent/Legal Guardian First: Home Phone: Email:

Food /Medical Allergies:

Zip Code: GPA:

EMERGENCY CONTACT

Address:

Insurance Name: & Medical Number:

Phone:

Phone: Zip:

Doctor’s Name:

PARENT / GUARDIAN INFORMATION Last: Last:

Cell:

Work: HEALTH ALERTS

SIGNATURES

I Authorize the verification of the information provided on this form to be correct. I have received a copy of this application: SIGNATURE OF PARENT/GUARDIAN: __________________________________________DATE:_____________________