Your Full Name (required)
Your Email (required)
Your Child's Full Name (required)
Child's Age
Child's Sex
Child's Height
Child's Weight
Child's Date of Birth
School
Grade
Person to notify in case of emergency:
Phone Number of Emergency Contact
MEDICAL CONCERNS/ ALLERGIES OF PLAYER (If none write none, if yes, please describe and see the academy director)
WAIVER / INDEMIFICATION
Parent(s) or legal guardian must sign below before player is accepted to participate in the Brookline /junior Tennis Academy: As parent/legal guardian of the child name herein, I hereby represent that the child has been examined by a pediatrician and is physically fit to participate in the Brookline Tennis Junior Academy. I understand there are inherent risks in participating in this athletic program. I hereby accept responsibility for and agree to pay any and all costs of medical treatment resulting from any injury suffered by my child as a result of his/her participation at the Brookline Tennis Junior Academy. I further agree to indemnify and hold harmless Pine Manor College, Brookline Tennis, its agents, servants, employees and/or representatives from any and all liability, damage, cost or expense arising out of my child's participation, of every kind and nature, at the Brookline Tennis Junior Academy. In the event that I cannot be reached in an emergency, I hereby give permission for care to be administered by a qualified staff member, emergency medical technician, physician/staff of a hospital, or any qualified individual to provide any medical treatment deemed necessary for my child.
Signature by parent or legal guardian
Date
My child's physician's form: is attached to this document (attach below)will be mailed to Brookline Tennis Academy
Medical Forms
Additional Comments
