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2006 APPLICATION & MINOR'S ENROLLMENT FORM |
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Filling out this Application, speeds up the paperwork process, it will not assure a pre-registration status for any particular date, time, you may have an interest in attending, be certain to fill out this application completely, one can mail in advance to: Ambassador Racing School, 14840 Speedway Drive, Wimauma, Florida, 33598, Ambassador will contact all applicants regarding their applications, scheduling, in the order applications are received, for faster scheduling, confirmation, or more information, contact the school direct, by calling: (813) 634-1076. |
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GUARDIAN/S - PARENTAL INFORMATION |
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| Father's Name (Last, First,
Middle):
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| Mother's Name (Last, First,
Middle):
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| Home Address:
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| City: | State: | Zip: | |||||||||||||||||||||||
| Home Phone: | Business Phone: | ||||||||||||||||||||||||
| Mobile Phone: | E-Mail: | ||||||||||||||||||||||||
| In Case of Emergency
Contact/s Name (Last, First, Middle, Relationship to student):
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| Emergency Contact/s Phone
Number/s:
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| Type of course you are
applying for (Check all that apply): [__] Quarter Midget / Driver Training [__] Quarter Midget Chassis Technology [__] Kart / Driver Training [__] Kart Chassis Technology
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| What Day/s could the student
attend? [__] Monday [__] Tuesday [__] Wednesday [__] Thursday [__] Friday [__] Saturday [__] Sunday
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| What Time frame could the
student attend? [__] Morning (9:00 a.m. to Noon) [__] Afternoon (1:00 p.m. to 4:00 p.m.) [__] Evening 6:00 p.m. to 9:00 p.m. |
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STUDENT INFORMATION |
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| Name (Last, First, Middle):
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| Gender: [__] Male [__] Female | |||||||||||||||||||||||||
| Students Age: | |||||||||||||||||||||||||
| Students Date of Birth: | |||||||||||||||||||||||||
| School (Name, City, State):
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| Highest level of education
completed: [__] K [__]1 [__]2 [__]3 [__]4 [__]5 [__]6 [__]7 [__]8 [__]9 [__]10 [__]11 [__]12
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| Does student have special
medical needs? [__] Yes [__] No (If Yes, explain):
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| Does student take prescribed
medications? [__] Yes [__] No (If Yes, explain):
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| Is student color-blind? [__]
Yes [__] No
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| Student's History - (List all
sports experience, club, or social activities or achievements):
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| Additional Notations about
student we should be aware of:
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| PLEASE READ, CHECK, AND SIGN | |||||||||||||||||||||||||
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(Place a check mark in the box [__] next to each segment after reading) In Consideration of my Minor Child being permitted to participate in any way in any instructional class, I agree:
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| [__] I know the nature
of the event/s and the Minor's capabilities, and believe the Minor to be
qualified to participate in the event/s. [__] I understand I will be asked to sign a Parental Consent form prior to my Minor's participation in any event/s. [__] I understand the purpose of these event/s is to provide individuals the opportunity to experience Quarter Midget, or Kart motor sports, and obtain technological information related to motor sports. [__] I understand that at least one parent or a legal guardian must be present during each class. [__] Student/s must wear long pants, closed shoes, socks that cover the ankles for the driving portion of the class. [__] Cost of each session is $ 50.00 per student per hour. [__] Student/s must reserve and pre-register for placement, and any balance due prior to the start of the first class. [__] A Certificate of Achievement is available upon request, for each student, upon final approval of the Instructor. [__] 'No Refund' will be provided for any dates missed by the student. [__] 'Credit Only' shall be honored towards a rescheduling when due to weather conditions if class can not be held. [__] 24 hour notice must be given if a student can not attend their scheduled class in order to reschedule. [__] Transportation of student/s to and from the school shall be my responsibility. AMBASSADOR RACING IS A PRIVATE FACILITY, and reserves the right to refuse anyone enrollment, participation or completion of any program/s. Be advised that should any student be deemed incapable of participating for what ever reason, cause a disturbance, become disrespectful, the parent or legal guardian will be asked to remove the student immediately. Legal Guardians Signature: ___________________________________________Date:_____________________ Legal Guardians Signature: ___________________________________________Date:_____________________
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| [FOR OFFICE USE ONLY] | |||||||||||||||||||||||||
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PROVIDE METHOD OF PAYMENT [__] Personal Check # _____________________ [___] Cash [__] Company Check # _____________________
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