Youth Wheelchair

Youth Wheelchair!

Registration Form
One application must be submitted per participant.

Enrollment will not be considered complete until ALL information is accurately submitted along with any applicable accompanying documentation.

For detailed program information, please visit www.corta.org

To register, either: Complete this form or submit via email to edna@corta.org|

Day: Friday, May 10
Time: 4:30pm - 6:00pm
FREE

Cooper Creek Park
5050 Cooper Creek Parkway
Player Name

First NameLast Name
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Age
Grade
School Name
Qualify for Free & Reduced Lunch?
T Shirt Size
Age Group?
Which location?
Learning Disabilities?
If yes, please describe:
Medical/Physical Restrictions?
If yes, please describe:
Dietary Restrictions/Food Allergies?
If yes, please describe:
Parent/Guardian Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
If you accept the terms of the above COVID-19 Wavier, please enter your name below. If player is not 18, please enter Parent or Guardian name

First NameLast Name
Signature
Should be Empty:

Youth Wheelchair!