Pete Brown Junior Registration Form

Child Name

Child Name*

First NameLast Name

Multiple Children Name, date of birth, and ages.

Birth Date*

MonthDayYear

Grade*

Gender*

MaleFemale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

E-mail*

example@example.com

Name*

First NameLast Name

Home Number*

Cell Number*

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Alt. Phone Number*

Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe.*

Is the athlete prescribed an inhaler? If yes, please explain any instructions.

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Pete Junior Tennis Program (PBJTP). during the selected camp. In exchange for the acceptance of said child’s candidacy by (PBJTP)., I assume all risks and hazards incidental to the conduct of the activities, and release, absolve and hold harmless PBJTP. and all its respective officers, agents, and representatives from any and all liability for injuries to the said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against PBJTP. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including tennis. Some of these injuries include but are not limited to, the risk of fractures, paralysis, or death.

Media/Medical Release

I First Name Last Name , (child) of blank (address), First Name Last Name (parent), or First Name Last Name (guardian) (check one) of the above-listed minor, hereby give my permission to Pete Brown Junior Tennis Program (PBJTP) to use photographs, voice recordings, or video taken of the above listed minor during the games and events associated with Pete Brown Junior Tennis Program (PBJTP) in any manner to help promote the league activities as determined in the sole discretion of the Local League. Such use could include publications, media releases, public announcements, electronic or otherwise, and on league websites or social media pages. I agree that neither I, nor the above-listed minor, will receive any compensation if such image appears in any of the manners listed above or another manner that the league deems appropriate. I agree that such an image is the property of the Pete Brown Junior Tennis Program (PBJTP).

Medical Release and Authorization As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the {Organization} . and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

T-Shirt Size*

SmallMediumLargeEx-Large

Signature*

Date

Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.