WORLD CLASS JUNIOR TENNIS Summer 2005

Joanie Schneebaum – Director, 410-531-0881

Circle the week(s) you wish to attend: Camp is held at Wilde Lake Tennis Club!

SESSION 1: June 20– June 24 SESSION 2: June 27 – July 1

*SESSION 3: July 5 – July 8 SESSION 4: July 11 – July 15

SESSION 5: July 18 – July 22 SESSION 6: July 25 – July 29

SESSION 7: August 1 –August 5 SESSION 8: August 8 – August 12

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

CA Members: $175/ 1 week CA Members: $335/1 week

Non-CA Members: $200/1 week Non-CA Members:$350/1 week

*Session 3: $140/1 week – CA. *Session 3: $270/1 week – CA.

*Session 3: $160/1 week – Non CA. *Session 3: $285/1 week – Non CA.

NAME: _______________________________________________________________________

ADDRESS: _____________________________________________________________________

TELEPHONE (Home) _________________________MOBILE #________________________

SESSION:_______COST:________ DATES:___________ M/F:__________AGE________ RECEIPT#____________

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

Are any adaptations needed for your child?____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:______________________________

Doses of medications:__________________________

Physician Name:_____________________Phone Number:____________________________________________________

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 Deadline is Friday, June 3, 2005.