2012 Carolina Trackout Science and Math Academy Camp Registration Form

Child #1 (Required)
First & Last Name   Preferred Name
Date of Birth   Current Grade Level
Allergies
Special Needs
School   Calendar

Week Selection for this Child:

Track 1 Track 2 Track 3 Track 4
















Apr 16








Mar 26
Child #2
First & Last Name   Preferred Name
Date of Birth   Current Grade Level
Allergies
Special Needs
School   Calendar

Week Selection for this Child:

Track 1 Track 2 Track 3 Track 4
















Apr 16








Mar 26
Child #3
First & Last Name   Preferred Name
Date of Birth   Current Grade Level
Allergies
Special Needs
School   Calendar

Week Selection for this Child:

Track 1 Track 2 Track 3 Track 4
















Apr 16








Mar 26







Parent / Guardian 1 (Required)   Address, City, State, Zip (Required)
Work Phone   Mobile Phone
Home Phone   Email Address (Required)
         
Parent / Guardian 2   Address, City, State, Zip
Work Phone   Mobile Phone
Home Phone   Email Address
         
Other Emergency Contact   Relationship
Work Phone   Mobile Phone
Home Phone   Email Address
         
Primary Physician (Required)   Address, City, State, Zip
Office Phone (Required)      
         
Insurance Carrier (Required)   Insurance ID # (Required)
Phone Number   Policy Holder