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R A L E I G H P A R K S, R E C R E A T I O N A N D C U L T U R A L R E S O U R C E S

16

*Last Name___________________________ *First Name__________________________ Preferred Name______________________

*Address_______________________________________________________________________________________________________

*City/State/Zip_______________________________________________________Home Phone_ ______________________________

Date of Birth____________________Age_ ____________ Grade (2016–2017)_ ______________________Gender_______________

*School_ _______________________________________________

a

Year-Round Track #_ _____

a

Traditional

a

Modified

T-shirt Size (Track Out Only):

a

YS

a

YM

a

YL

a

YXL

a

AS

a

AM

a

AL

a

AXL

Name of Child’s Doctor, Phone Number & Address_ ________________________________________________________________

_______________________________________________________________________________________________________________

Name of Child’s Dentist, Phone Number & Address_________________________________________________________________

_______________________________________________________________________________________________________________

Insurance Carrier & Policy #_ _______________________________ Hospital Preference____________________________________

Parent/Guardian Information

(Please indicate person who is the main contact and preferred contact method.)

a

*Parent/Guardian Last Name_ ___________________________ *First Name____________________________________________

a

*Home #_ ________________________

a

Work#_ ____________________________

a

Mobile #___________________________

*Address________________________________________________ *City/State/Zip_________________________________________

*Email address____________________________________________________________ Employer_ ____________________________

a

*Parent/Guardian Last Name_ ___________________________ *First Name____________________________________________

a

*Home #_ ________________________

a

Work#_ ____________________________

a

Mobile #___________________________

*Address________________________________________________ *City/State/Zip_________________________________________

*Email address____________________________________________________________ Employer_ ____________________________

Emergency Contact/Release Authorization

List in order the names of those other than the parent/guardian above who are to be contacted in case of an

emergency and are authorized to pick up the participant. Authorized individuals must be 16 or older and will be

required to show a picture ID. Please print all names.

1. Name _ ________________________________________________ Relationship to Child___________________________________

Address _ ________________________________________________ City/State/Zip_ ________________________________________

*Home #_ __________________________

a

Work#_ ____________________________

a

Mobile #___________________________

a

Please check to authorize staff to disclose information about the participant’s behavior and activities in this program.

2. Name _ ________________________________________________ Relationship to Child___________________________________

Address _ ________________________________________________ City/State/Zip_ ________________________________________

*Home #_ __________________________

a

Work#_ ____________________________

a

Mobile #___________________________

a

Please check to authorize staff to disclose information about the participant’s behavior and activities in this program.

*All fields must be completed.

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2016-2017 Registration

(cont.)

Participant Information

Please complete in ink.