2007 Whitley Park Junior Tennis Camp

Registration Form
Camper's Name __________________________________________________
Camper's Age/Birthdate/Sex __________________________________________________
Parents' Names __________________________________________________
Address __________________________________________________
City, State, Zip __________________________________________________
Home Phone __________________________________________________
Mother's Work/Cell Phone __________________________________________________
Father's Work/Cell Phone __________________________________________________
E-Mail Address __________________________________________________
Emergency Contact
(Name & Phone)		 __________________________________________________
Family Doctor
(Name & Phone) 		__________________________________________________
Do you carry medical insurance? ___Y  ___N
Name of Insurance Carrier __________________________________________________
Group Name & Policy Number __________________________________________________
Is your child currently enrolled in a Maryland public or private school? ___Y   ___N If not, pursuant to MD law, you must provide a copy of your child's immunization history, filled out by your physician.
What was the date of his/her last tetanus shot? _____________(MUST be answered for your child to attend camp)
CAMP SESSION(S) REQUESTED __________________________________________________


The fee is $300 per camper for each session. Payment in full is due by June 1, 2007.

Please make checks payable to RPM SPORTS, INC. Send to Richard McMichael, RPM Sports at Whitley Park, 5450 Whitley Park Terrace, Bethesda, MD 20814.

WAIVER

As parent or guardian of the above named child, I hereby agree to assume complete financial responsibility for any personal injury or property damage created as a result of an intentional or negligent act of my child or ward while attending the 2007 Whitley Park Junior Tennis Camp.

I hereby waive and release any and all rights and claims I may have or hereafter acquire against RPM Sports, Inc., Richard McMichael, his assistants, Whitley Park Condominium Association, its members or employees for any and all injuries, damages, or losses which may be suffered by my child or ward in connection with his/her activities at the Whitley Park Junior Tennis Camp.

I understand and agree that the Whitley Park Junior Tennis Camp shall retain the right to dismiss any child whose behavior is detrimental to the normal operation of the camp. No refund will be made in such a case.

To the best of my knowledge, there are no physical or other conditions which will interfere with my child's participation. I certify that my child or ward has had a medical examination within the last 12 months and, in the physician's opinion, is physically capable of completing the camp session(s) for which she/he has registered.

In case of emergency, if parents, emergency contact, or child's physician cannot be reached by phone, I hereby give my consent to the Whitley Park Junior Tennis Camp and to any agent acting on its behalf to secure and provide any medical treatment that might be necessary in case of injury or sickness, while attending the camp. I hereby give permission to the physician selected by the Whitley Park Junior Tennis Camp to hospitalize, secure proper treatment for, and order injection, anesthesia or surgery for my child or ward as named above. I further agree to accept responsibility for any medical expenses incurred on behalf of my child or ward under the conditions described above. I understand that any accident or sickness claim will be covered by the parents' or guardians' insurance policy.


_____________________________
Parent/Guardian's Name (Please print)
 _____________________________
Signature of Parent/Guardian
_____________________________
Date