Rising Stars Track Club - Online Registration

Please complete the following form to register for the Rising Stars Track Club 2008 season:

MEMBERSHIP TYPE

Recreation Team:
Training Only:

Club Team:
High School:

Click here for team information

ATHLETE REGISTRATION

FIRST NAME:

LAST NAME:

MIDDLE INIT:

GENDER:
Female Male

DATE OF BIRTH:
(Ex. ##/##/##)

ATHLETE TYPE:

Hold down CTRL key to select multiple items.

ADDRESS INFORMATION

ADDRESS:

CITY:

ZIP:

HOME PHONE:

EMAIL:

MEDICAL INFORMATION

DOCTOR NAME:

PHONE:

MEDICAL INSURANCE CARRIER:

MEDICAL RECORD #:

DATE OF LAST PHYSICAL:

Please check all that apply:
Sight:	Hearing:	Respiratory:	Orthopedic:
Other:	Please specify:

PARENT INFORMATION

FATHER FIRST NAME:

FATHER LAST NAME:

ADDRESS:

CITY:

ZIP:

HOME PHONE:

CELL PHONE:

WORK PHONE:

MOTHER FIRST NAME:

MOTHER LAST NAME:

ADDRESS:

CITY:

ZIP:

HOME PHONE:

CELL PHONE:

WORK PHONE:

EMERGENCY CONTACT INFORMATION

CONTACT FIRST NAME:

CONTACT LAST NAME:

ADDRESS:

CITY:

ZIP:

HOME PHONE:

CELL PHONE:

WORK PHONE:

REPORT CARD

Enter grades in this format: A = 4, B = 3, C = 2, D/F = 1

SCIENCE:	SOCIAL STUDIES:	ENGLISH/READING:	MATH:

P.E.: