Charlotte Champions Extreme Camp Application (OVERNIGHT CAMP)
Summer 2025
Does your student live in the Lakeview Community or attend Faith Memorial MBC?
Yes
No
Student Information
Students Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Grade
*
Current School
*
Gender
*
Please Select
Male
Female
N/A
Are you of Hispanic, Latino, or Spanish origin?
*
No
Yes
Regardless of how you answered the last question, please indicate how your child identifies their race. (Select as many as apply.)
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino descent (Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture)
White
Other
Student has an Individual Educational Plan?
*
Yes
No
Would your child like to participate in Bike Camp?
Yes
No
Need more details
Parent(s)/Guardian(s) Information
Parent / Guardian 1
*
First Name
Last Name
Relationship
*
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
What is your age?
*
18 to 24 years
25 to 34 years
35 to 44 years
45 to 54 years
55 to 64 years
Age 65 or older
What is the highest degree or level of education you have completed?
*
Less than high school
High School graduate (includes equivalency)
Some College, no degree
Associate's degree
Bachelor's degree
PH.D.
Graduate or professional degree
Parent / Guardian 2
First Name
Last Name
Relationship
Phone Number
-
Area Code
Phone Number
Email
example@example.com
What is your age?
18 to 24 years
25 to 34 years
35 to 44 years
45 to 54 years
55 to 64 years
Age 65 or older
What is the highest degree or level of education you have completed?
Less than high school
High School graduate (includes equivalency)
Some College, no degree
Associate's degree
Bachelor's degree
PH.D.
Graduate or professional degree
What was your total combined household income before taxes the past 12 months?
*
Less than $25,000
$25,000 to $34,000
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $149,000
$150,000 to $199,999
$200,000 or more
Emergency Information
Please list in order of whom to contact first
*
Health Information
Family Doctor
First Name
Last Name
Clinic
Phone Number
-
Area Code
Phone Number
Please let us know if this child have any allergies
*
List medications if this child is currently taking
*
Have this child had any serious illnesses or operations?
*
No
Yes
If yes, please describe
Can this child take part in regular physical activities?
*
Yes
No
Do you want to indicate any related information?
Date of Registration
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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