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: