Pmahata@verizon.net

REGISTRATION FORM FOUND BELOW

PLEASE FILL IN INFORMATION AND SEND TO

PAUL MAHATA

824 BENNETT ROAD

MOUNT AIRY, MD 21771

 To contact Rotarian Paul Mahata, Tel: 301-275-9730, E-mail:  Pmahata@verizon.net

REGISTRATION FORM for Youth Tennis Tournament                                       Page 1 of 2

Date of Tournament: May 19, 2012

Place: South Carroll High School tennis facility

Parents are required to fill out both sides of this registration form and sign it.  Mail this form to Rotary Club of Mt. Airy, PO Box 531, Mt. Airy, MD 21771, with entry fee ($20 per participant before May 12).  Participants are also encouraged to get individual sponsors and collect donations ($20 or more).  Make all checks payable to Rotary Club of Mt. Airy.

Participant Information:

Name___________________________________________                   Boy_________  Girl___________

Grade in Spring ’11-’12:     3^rd____ 4^th____ 5^th____ 6^th____ 7^th____ 8^th____9^th____10^th____11^th____ 12^th____

School attending _______________________________________________________________________

Home address__________________________________________________________________________

Contact phone numbers ____________________ ______________________________

E-mail address (of parent) _________________________________________________________________

Tennis proficiency:       Beginner_________   Intermediate____________  Advanced___________

How did you know about this tournament?     Newspaper ad/article_________   Posters in stores/clubs/tennis courts__________  Rotary web site_______ Rotary member________  Friends________ Other__________

Parents Information:

Mother’s  name & tel #__________________________     Father’s name & tel#____________________________

REGISTRATION FORM for Youth Tennis Tournament                                       Page 2 of 2

Parent Declaration and Release:

I agree that I will provide supervision for my child and any of his/her guests at the tournament or the surrounding areas. I am aware that, while tennis is considered a non-contact sports, accidents and injuries DO occur, either through direct play in the tournament or activities related thereto.  I hereby agree that, in the case of an accident or injury involving my child, I release the Rotary Club of Mt. Airy, all of its members, agents, designees and assigns from any and all liability in connection therewith.   I agree that I will indemnify and hold Rotary Club of Mt. Airy harmless in connection with any such accident or injury and any action taken as a result thereof.  I understand the Rotary Club of Mt. Airy does not provide medical coverage or medical insurance and that it is my own responsibility to provide for medical insurance and coverage for my child.  I further authorize any volunteers, tennis tournament coordinators, Rotary members and/or referees to provide medical attention (however they are not obligated to do so) if they believe same is necessary and I release them from any liability in the event they do take such action.  

 ________________________________________                    _________________________________

Parent Signature                                                                                  Date

Medical concerns______________________________________________________________________

Medical/Health Insurance Company_____________________________________________________________

Contact:  For registration and information regarding this youth tennis tournament, please visit the web site: www.mountairyrotary.org , or contact Rotarian Paul Mahata (Pmahata@verizon.net Tel: 301-275-9730)