RSTC 2012 Online Registration
Please complete the following form to register for the Rising Stars Track Club 2012 season:
Athlete Information:
First Name:
Last Name:
Middle Initial:
Gender:
Female Male
Female Male
Birthdate:
(Ex. ##/##/##)
(Ex. ##/##/##)
Athlete Type:
Hold down CTRL key to select multiple items.
Address Information
Address:
City:
Zip:
Home Phone:
Email:
Medical Information
Doctor Name:
Doctor Phone:
Insurance Carrier:
Medical Record #:
Date of Last Physical:
(Ex. ##/##/##)
(Ex. ##/##/##)
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.: