2655 SIDNEY STREET,  CHATTANOOGA, TN 37408  |  423.321.3999

 
 PITCHER PREFECT SWING STUDENT REGISTRATION

  STUDENT INFORMATION
Student's Name:
Last: First: Middle:
Birth Date:
Address: 

 

City:     State:      Zip: 
Home Phone:       Cell Phone: 
School Attending:   

Name(s) of siblings:

Lives with (Select One):

  Both Parents     Mother      Father      Other (Custodial Parent)
 
  PARENT INFORMATION
Mother's Name:
     
Address (If Different): 

 

City:     State:      Zip: 
Home Phone:      Work Phone:    Cell Phone: 
Employer:     Email Address:  
Father's Name:
     
Address (If Different): 

 

City:     State:      Zip: 
Home Phone:      Work Phone:    Cell Phone: 
Employer:     Email Address:  
  EMERGENCY INFORMATION
Emergency Contact
Person(s) who can be reached in case of emergency, if parent cannot be reached:
 
Name:    Phone:
     
Name:    Phone:
     
In case of emergency and I cannot be contacted, take my child to:
(Hospital) 

        I (Parent/Guardian) will assume financial responsibility Yes   No
 
Family Doctor:    Phone:
Date of Last Physical: 
Is there a court order/decree prohibiting anyone from picking up your child?  Yes   No

Persons permitted to pick up your child: