NAME OF PARTICIPATE    DATE OF BIRTH  

 

GRADE THIS FALL    T-SHIRT SIZE    E-MAIL  

 

PARENT OR GUARDIAN’S NAME    

 

ADDRESS    CITY  

 

STATE    ZIP CODE  

 

PHONE NUMBERS:  CELL    HOME   WORK  

DO YOU RECEIVE TEXT MESSAGES?  

 

EMERGENCY CONTACT  PHONE  

 

NAME OF ALL PARTIES AUTHORIZED TO PICK UP PARTICIPATES AND PHONE NUMBER

DOES PARTICIPATE HAVE MEDICAL INSURANCE?  Yes     No

 IF YES, WHAT IS NAME OF PROVIDER AND POLICY OR CERTIFICATE NUMBER  

 

DOES PARTICIPATE HAVE ANY HEALTH OR PHYSICAL ISSUES WE NEED TO BE AWARE OF?      Yes        No

  IF YES, PLEASE FULLY EXPLAIN  

 

My child has had a recent physical examination and is able to participate in league play.  I hereby release the Franklin Youth Tennis Association and volunteers from all liability from injury or illness incurred while participating in league play.  I hereby authorize volunteers and officials from the Franklin Youth Tennis Association to act on my behalf according to their best judgement in any emergency situation.

 

Signature       Date                           

 

                               Click here to go to Waiver and Release of Liability form