Professional Tennis Services @ South Riding, VA

Registration Form (please print)

(Must be completed and signed by EVERY participant, can be copied for multiple players)

Child’s Name: _______________________________________

Date of Birth ______/________/________

Parent’s Name: ___________________________ Home Phone______________

 Work Phone: ____________ Email (mandatory) ________________________­_

 Street________________________ City__________________ Zip________

Adult Player’s Name: _______________________________________

Home Phone______________ Work Phone: ____________

 Email (mandatory) ________________________­________________________

 Street________________________ City__________________ Zip________

Level: __ Beginner __ Adv Beginner __ Intermediate __ Advanced

No spot held without registration and total fees paid.

I fully understand that there are no refunds, except with a doctor’s note for medical emergency only.  I release Professional Tennis Services, Big A Tennis Services, Town of South Riding its principals, officers and all personnel thereof, from all liability resulting from personal injury to my child and or myself.  I release permission to use photos taken during class to help promote the program in press releases, flyers, newsletters and Email newsletters.*

* no student will be identified by name in published photo without that student’s/parent’s permission.

Signature: _____________________________________________ Date_________________________

Checks payable to James Grein - 873 Old Holly Dr - Great Falls, VA 22066