CAROLINA DREAMS PARTICIPANT APPLICATION

APPLICANT INFORMATION
Child's Name:
Date of birth:
Phone:
Current address:
City:
State:
ZIP Code:
E-mail:
Tee-Shirt Size:
Medical History
(optional; this information will not be disclosed outside this office):
PARENT/GUARDIAN INFORMATION
Parent's Name:
Current address:
City:
State:
ZIP Code:
Daytime Phone:
Evening Phone:
E-mail:
EMERGENCY CONTACT
Name of a contact not residing with you:
Address:
City:
State:
ZIP Code:
Phone:
Relationship:
REFERRING DEPARTMENT
Name:
Department:
Phone:
Nurse Doctor Other
UNC ATHLETIC EVENTS
Please rank order events you would like to attend 1-4; we will try to accommodate your first choice
Field Hockey vs. Duke at 1 p.m. at Henry Stadium on Saturday, September 26, 2009
Football vs. Georgia Southern at TBD at Kenan Stadium on Saturday, October 10, 2009
Women's Soccer vs. Clemson at 7 p.m. at Fetzer Field on Thursday, October 29, 2009
Football vs. Duke at TBD at Kenan Stadium on Saturday, November 7, 2009
PARENT/GUARDIAN ATTENDING EVENT
Name:
Date: