Registration for Project Alpha Leadership Training

Saturday April 19, 2008 | Fretwell Building - UNCC | 9:00 am - 4:30 pm

PLEASE COMPLETE ONE (1) FORM PER STUDENT

Please complete the form below. All information is required. You will be contacted within 24 hours to verify that you're application has been completed.

Please provide the following contact information:

Name DOB
Street Address Sex:   MF
Address (cont.) Disability:
City

T-Shirt Size:

State/Province School Attending:
Zip Code

Grade:

Country Dietary Needs (Food Allergies): 
Home Phone
E-mail
Parent/Guardian Name:
Work Phone
Home Phone
E-mail

In case of emergency contact (Name):

Name
Phone

Consent and Release

I  hereby grant permission for the participant to take part in the “Project Alpha Leadership Training” program, which is sponsored by the Mecklenburg County Park and Recreation Department, March of Dimes and Alpha Phi Alpha Fraternity, Inc.

  I also agree, on behalf of myself and the participant, not to make any claims or demands of any kind against Mecklenburg County or any of its employees or agents for any loss or injury that the participant might sustain while engaged in the “Project Alpha Leadership Training” program including transportation to and from the program site.

  I authorize such physician or medical staff as the Mecklenburg County Park and Recreation Department my designate to carry out any minor medical/surgical treatment and/or medication necessary, or to take the participant to the nearest emergency facility, and I/we further authorize its medical staff to provide any treatment deemed necessary for the well-being of participant.

  I also agree that photographs of the participant may be published for the purpose of publicizing and promoting programs operated and/or sponsored by the Mecklenburg County Park and Recreation Department.
 

Name of Parent(s)/Guardian    Date

By entering your name and the date above, you agree to the terms outlined in the consent and release