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: 3rd____ 4th____ 5th____ 6th____ 7th____ 8th____9th____10th____11th____ 12th____
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)