Mardi Gras Tennis Camp Registration

Mardi Gras Tennis Camp
*If you have any questions, contact Carlos Himpler at carloshimpler@yahoo.com or 225-303-1055.
Tennis Camp Registration
Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Email*
*Important camp information and updates will be sent to the email address on file.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child Information
Child's Name*

First NameLast Name
Child's Gender*
Child's Date of Birth*

MonthDayYear
Child's Age*
YesNo
If yes, please list below:
YesNo
If yes, please list below:
Other Known Conditions
*If none, please skip
*If you are registering a second child, please fill out the fields below.
Child's Name (second)

First NameLast Name
Child's Gender (second)
Child's Date of Birth (second)

MonthDayYear
Child's Age (second)
YesNo
If yes, please list below:
YesNo
If yes, please list below:
Other Known Conditions (second)
*If none, please skip
*If you are registering a third child, please fill out the fields below.
Child's Name (third)

First NameLast Name
Child's Gender (third)
Child's Date of Birth (third)

MonthDayYear
Child's Age (third)
YesNo
If yes, please list below:
YesNo
If yes, please list below:
Other Known Conditions (third)
*If none, please skip
Emergency Contact

The person(s) listed below are authorized to pick up my child/children from Mardi Gras Tennis Camp. Your child/children will only be released to the people on this list. Please note this procedure is for the safety of your child.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relation to child/children*
Emergency Contact #2
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relation to child/children
Emergency Contact #3
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relation to child/children
Session(s) Requested
Feb 17thFeb 18thFeb 19thFeb 20thFeb 17th - 20th
Camp Fee: $40 per dayCamp Fee: $160 per week (T-F 9am - 1pm)
Payment Method
Please make payment at https://venmo.com/u/ashleyhimpler
Liability Waiver and Photo Release
Relation to child*
Release statement: The undersigned parent or legal guardian of the child/children listed above hereby consents and authorizes participation in Mardi Gras Tennis Camp. I understand that my child/children will engage in a number of sports and activities that require physical exertion and acknowledge that there is a risk of personal injury to my child/children. In consideration for Mardi Gras Tennis Camp accepting the above names children into the tennis camp, I do hereby for myself, my spouse, my children, my heirs, personal representatives and assigns, forever discharge Carlos Himpler, its agents, servants, associates, officers, directors, affiliates, sureties, successors, and either in law or equity, arising from or as a result of my child/children's participation in Mardi Gras Tennis Camp.
Name of parent or legal guardian*

First NameLast Name
Photo Release Form: I grant permission to Mardi Gras Tennis Camp, its agents, and its employees the irrevocable and unrestricted right to produce photographs and video taken of my child/children, myself, and members of my family while at Mardi Gras Tennis Camp for any lawful purpose including publication, promotion, illustration, advertising, trade, or historical archive in any manner or in any medium. I hereby release Mardi Gras Tennis Camp and its legal representatives from liability for any violation or claims relating to said images or video. Furthermore, I grant permission to use the statements of my child/children, myself, or my family members given during an interview or evaluation with or without my name for the purpose of advertising and publicity without restriction to time limit or geographic area. I waive my right, my child/children's rights, and my family’s rights to any and all compensation stemming from the use of these materials.
Name of parent or legal guardian*

First NameLast Name
Relation to child*
Signature*

Powered by Jotform SignClear
Should be Empty:

Mardi Gras Tennis Camp

Tennis Camp Registration

Parent/Guardian Information

Child Information

Emergency Contact

Emergency Contact #2

Emergency Contact #3

Session(s) Requested

Payment Method

Liability Waiver and Photo Release