Giammalva Academy/12&under/JH&HS registration Form

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Family Name* This field is required.
2
Father's Name* This field is required.
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Mother’s name* This field is required.
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Address* This field is required.
Street Address
Street Address line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Phone Number* This field is required.
Area Code
Phone Number
6
Email* This field is required.
example@example.com
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Select Program* This field is required.select what the group you would like to register
Elite Academy
MultiSport Camp
Transition Academy
12&Under
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1. Player Name* This field is required.
First Name
Last Name
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1. Player Birth Date* This field is required.Enter Player 1 DOB
Month
Day
Year
10
1. Allergies and/or Medications * This field is required.
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2. Player Name If more than one student registering
First Name
Last Name
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2. Player Birth DateInfo from player 2
Month
Day
Year
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2. Allergies and/or MedicationsInfo from player 2
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3. Player NameIf more than one student registering
First Name
Last Name
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3. Player Birth DateInfo from player 3
Month
Day
Year
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3. Allergies and/or MedicationsInfo from player 3
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Select Days or Weeks Summer camp 2021
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AUTOMATED CHARGE DEBIT/DRAFT DRAW AUTHORIZATION* This field is required.I realize all program fees and program guest fees incurred by my family will be automatically drafted from my checking/charge account. I also realize that I may cancel my child's program by giving written notice at least ten (10) days before the next month Program start date. I have given authorization to the institution/card listed below to honor preauthorized check/charge transaction drawn by Giammalva Racquet Club. I realize that my bank/account statement will constitute receipt for payment. I also realize that if pre-authorized check/charge draw is not honored by said institutions, I am responsible for total payment by other means of transaction. As a convenience to me, I hereby request and authorize you to pay and charge my check/charge draw on my transaction. As a convenience to me, I hereby request and authorize you to pay and charge my check/charge draw on my account by and payable to the order of Giammalva Racquet Club provided there are sufficient funds/credit in said account to pay same on presentation. I agree that your rights in respect to each debit shall be the same as if it were a check/charge drawn on you and signed personally by me. This authority is to remain in effect until revoked by me with a ten-day written notice and until you receive such notice. I agree that you should be fully protected in honoring such check/charge.
ClearSignature Required
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TERMS AND CONDITIONS * This field is required.1. Resignation Agreement: It is agreed that Applicant may resign from the program by giving ten (10) day written notice before next month program start day in writing to the club. The effective date of the resignation will be the date the club receives Applicants written notice. All accrued program fees and other charges for which Applicant is liable are due upon the effective date of resignation. 2. Makeup Agreement: Classes missed due to student illness, vacation and/or other personal reasons will not be made up. If a student has an extended medical condition or emergency, please contact the Pro in charge of the program so that special arrangements can be made. 3. Payment Agreement: Applicant Agrees to pay the account when due. Applicant agrees that the Club may asses a late charge of $25.00 for past due accounts. 4. Disclaimer and Hold Harmless Agreement: I accept full responsibility for my use, heirs and assigns use apparatus, appliances, faculty privilege or service whatsoever, owned and operated by the club, at my own risk, and shall hold this Club, its shareholders, directors, officers, employees, representatives, and agents harmless for any and all negligence, loss, claim, injury, damage, or liability sustained or incurred by me resulting there from. 5. Photo release: I give my permission to Giammalva Racquet Club to photograph/video and/or use a photograph of me, my family and children in publications, news releases, or Giammalva Racquet Club webpage, club newspapers, brochures, etc. 6. Medical Authorization Agreement: I authorize Giammalva RC Staff to seek any needed medical attention by a licensed physician/facility as be necessary for the safety and well-being of my child or children. 7.Prepaid semester fees will not be refunded if my child does not attend classes unless student has an extended medical condition or some other extenuating circumstance and agreed upon by Program Director.
ClearSignature Required
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Comments / Questions:
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THANKS FOR CHOOSING GIAMMALVA !
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