CTTA-Central Texas Tennis A

2010 CLINIC REGISTRATION

Name:

Age:

Date of Birth:

School:

Grade:

Gender:

Phone (H):

(W):

Other:

Home Address:

City/State/Zip:

Email Address:

In case of an emergency contact the following:

Name:

Number:

Relationship:

CTTA Offers:

Certified Professional Tennis Instructors

All staff and volunteers certified in CPR & First Aid

All equipment provided

Session / Program Tournaments

Selection:

Does your child require special care or any disabilities?

2009 Medical Information & Waiver Form

If yes, please specify:

Is your child currently taking any prescribed medication?

Does your child have an existing or previous illness?

Has your child been hospitalized in the past 12 months?

Does your child have any known allergies to foods, insect stings or medications?

I, the undersigned parent, binding heirs, executors, administrators, estate and assigns, do hereby release and agree not to hold liable CTTA, its board, instructors, volunteers, or agents; from any and all actions causes of action, claims, demands, costs or damages as a result of property damages or personal injuries or death sustained by me or my said child or his/her or my property. CTTA is not liable for me or my child or his/her property resulting in injury or harm while participanting in the Afterschool Fall Program activity or traveling to or from the place at which such activity will be conducted.

-- Consent is hereby given for the applicant to participant in the CTTA Fall Afterschool Program and permission is given for any emergency medical treatment, operation, or anesthesia, which might become necessary. I agree to be responsible for the expense of medical treatment of service.

Physician Name:

Physician's Telephone:

-- Consent is hereby given for the applicant to participant in the CTTA Fall Afterschool Program but permission is NOT given for any emergency medical treatment, operation, or anesthesia, which might become necessary. I DO NOT agree to be responsible for the expense of medical treatment of service.

Additional Information or Phone