CYT0002 Club Yellow Tops Registration Form Club Yellow Tops Registration Form (For School Health Educators) Please complete all sections of this form. 1. School Information: Name of School: School District: Contact Person (Your Name): Email Address: Phone Number: Mailing Address: 2. Role/Entry Option: Role/Entry Option: School Nurse School Dentist PE Instructor Guidance Counselor Homeroom Adviser Other (Please specify): Brief Description of Activities/Responsibilities as a School Health Educator: 3. Club Yellow Tops Specifics: Website (if applicable): Dates of Attendance: 4. Special Needs/Requirements: Dietary Restrictions: None Other: Special Accommodations Required: Yes No 5. Emergency Contact Information: Emergency Contact Full Name: Emergency Contact Relationship: Emergency Contact Phone Number: Emergency Contact Email Address: 6. Consent and Signature: I hereby certify that the information provided on this form is accurate and complete to the best of my knowledge. Signature: Date:
