Wilkes Heart of a Champion Day is currently only offered to Atrium Health Wake Forest Baptist partner high schools. Students that aren't at one of the following schools in the dropdown, will not be able to attend. Students are required to complete full registration with Parent or Guardian present.  *Please take the time, read through the questions, and answer to the best of your knowledge*
* = Required Information
This form is for the 2024-25 School Year
*Have you ever participated in Heart of a Champion Day before? Required	Yes No	If Yes, what years?
*Please select event timeslot: 'Select One' 9:15am 9:30am 9:45am 10:00am 10:15am 10:30am 10:45am 11:00am 11:15am 11:30am 11:45am 12:00pm  Required  Time slots can not be changed after registration is submitted
Personal Emergency Contact Information *School Attending Next Year: 'Select One' Alleghany High School Andrews High School Atkins High School Carver High School East Forsyth High School East Wilkes High School Forbush High School Glenn High School Grimsley High School High Point Central High School High Point Christian Academy Lexington High School Mt. Airy High School Mt. Tabor High School North Carolina Leadership Academy North Forsyth High School North Wilkes High School Parkland High School Ragsdale High School Reagan High School RJ Reynolds High School Southern Guilford High School Southwest Guilford High School Starmount High School Walkertown High School Wesleyan Christian Academy West Forsyth High School West Wilkes High School Wilkes Central High School Winston-Salem Prepatory Academy Other Required *Grade Entering: 'Select One' 9th 10th 11th 12th Other Required *First Name: Required Middle Initial: *Last Name: Required *Street Address: Required Apt/Unit: *City: Required *State: Required *Zip: Required     *Phone#: Required *DOB:   DOB mm/dd/yyyy *Age: Required Race: 'Select One' American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Two or More Races (not Hispanic or Latino) *Gender assigned at birth:  'Select One' Male Female Required     *Email: Required   Email will be used for further instructions
Parent/Guardian Information * Parent(s)/ Legal Guardian(s) Residing With: Required * Who Has Custody: Required * Fathers Name: Required * Alternate Phone (Work/Cell): Required * Mothers Name: Required * Alternate Phone (Work/Cell): Required Family Physician/Pediatrician: Physician Phone: *Preferred Hospital: Wilkes Medical Center Required *Permission To Transport To Hospital: 'Select One' Yes No Required  Page 1 of 9