JOANIE’S JUNIOR TENNIS  Summer 2009

Joanie Schneebaum – Director,  410-531-0881

 

WILDE  LAKE TENNIS CLUB

Circle the week(s) you wish to attend

 

SESSION 1:  June 22– June 26                                                        

SESSION 2:  June 29 – July 3

SESSION 3:  July 6 – July 10                                                              

SESSION 4: tournament week (NO camp)

SESSION 5: July 20 –July 24                                                                     

SESSION 6:  July 27– July 31

SESSION 7: August 3 - August 7

SESSION 8:  August 10– August 14           

SESSION 9: August 17- August 21                                                             

                 

    CIRCLE :           Half Day (9am-12noon): $ 200                  Full Day (9am-3:00 pm):   $350

             

 

Name_______________________________________

 

ADDRESS: _______________________________

 

E-Mail ____________________________

 

TELEPHONE: (Home)________________(Mobile)________________

 

SESSION:______________     COST:________

 

M/F:__________AGE________ RECEIPT#____________

 

Does child have a medical condition?    ____NO  _____YES (please explain)________________________________________

 

Does child take any medication?________NO _____YES (please explain)__________________________________________

 

Will child take medication during camp hours?____NO_____ YES ,

 

Name of Medications:______________________________

 

Physician Name:_____________________PhoneNumber:____________________

 

Is your child enrolled in a Maryland school for the 2005-2006 school year? ___ YES____NO

If no, send in copy of child’s immunization records. 

Is any part of the immunization record missing due to religious or medical reasons?  ___YES___NO

If yes, send in a copy of the release exemption form.  Month/Year of last Tetanus shot __________

Current Medical/Diet Restrictions_______________Allergies___________________________

 

Special conditions we should know about________________________________________________

 

EMERGENCY INFO:  The following contacts, who are aware that his/her names are being furnished, has permission to pick up my child and should be contacted in the event of an emergency if I cannot be contacted.

Contact Number 1:  Name_______________________________Phone:_______________

Relationship___________________

 

Contact Number 2: Name____________________________________________ Phone:____________________Relationship___________________

 

Please read carefully and sign.

 

______________________________(child’s name) has permission to participate fully in activities.  My child is in good health and has been seen by a physician within the past year.  In the event of a medical emergency, I hereby authorize the staff of the Columbia Association to authorize medical treatment for my child.  Permission is given to use pictures in which the above-named child appears in any Columbia Association promotion or publicity.  To the best of my knowledge, all information supplied is complete and accurate.  I further understand that this registration represents my agreement with the Columbia Association to pay the applicable tuition and fees when they become due.  I further understand that failure to pay the tuition and fees as they become due constitutes a default under the terms of this agreement for which my child’s registration will be cancelled and Columbia Association may pursue all legal remedies to collect any outstanding and unpaid tuition, fees and charges.

 

 

Parent/Guardian Signature______________________________________________________________Date______________

Please drop off form and check at the Owen Brown Tennis Club