2014 TPC SUMMER Junior Tennis Program
Intermediate & Advanced
MEMBER Registration Form
Participant’s Name(s): ___________________________
Parent E-mail address
_________________________
_____________________________________________
(E-mail for Camp ONLY)
Member Fee: Total amount due
Week 1
June 16 – 20th
Week 2
June 23 – 27th
Week 3
June 30th – July 2nd
Week 4
July 7th - 11th
$ __________
Bill my acct.
Week 5
Week 6
Week 7
Week 8
Week 9
**All Weeks are Monday – Friday except Week 3
Check enclosed
July 14-18th
July 21-25th
July 28-8/1
August 4-8th
August 11-15th
Member Fees: Please CHECK LEVEL of CLINIC you would like to register your child for:
LEVEL 3 - Training Camp Ages 7/8
LEVEL 4 - Training Camp
$400 per week*
1:30 - 4:30pm
Ages 9-12 $400 per week*
1:30 - 4:30pm
LEVEL 5 Training Camp
$400 per week*
10 am - 1pm
*approval from Director Scott Potthast or Jr. Coordinator Polo Cowan prior.
LEVEL 6 Training Camp
$400 per week*
10 am - 1pm
*approval from Director Scott Potthast or Jr. Coordinator Polo Cowan prior.
*25% off each week after first complete week is paid for.
Below, please circle EACH week you would like to register your child for.
Camper’s Name: _______________________Birth date__________ Level:_____
Camp Week #:
1
2
3
4
5
6
7
8
9
Camper’s Name: _______________________Birth date__________ Level:_____
Camp Week #:
1
2
3
4
5
6
7
8
9
CANCELLATION POLICY: I understand that NO REFUNDS will be given for the TPC Junior
Tennis and Swim Summer Program 2014 after 4:00pm Friday, May 30th.
____________________________________
______________________________
_________
Parent/Guardian Signature
Parent/Guardian Contact number
Date
Summer 2014
Summer Tennis Program
Medical Release Form
Child’s Name ____________________________
Child’s Name ________________________
Child’s Name ____________________________
Parents’ Name ________________________________________________
Home Phone #_________________________________________________
Cell Phone(s) # __________________________________________________
In case of emergency, please contact the following people (After parents/guardians):
1. ______________________________ Phone #s ___________________________________
2. ______________________________ Phone #s ___________________________________
Please list any special challenges, limitations, needs, medical conditions or allergies
each child (include name) may have that the Tiburon Peninsula Club camp staff needs to
be aware of or could help the coaches.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Please list any food allergies your child may have:
Child’s name ________________________ Food(s) ____________________________________
Child’s name ________________________ Food(s) ____________________________________
Child’s name ________________________ Food(s) ____________________________________
Please list your insurance carrier, policy#, and pediatrician:
Insurance Carrier _______________________________ ID # ______________________
Pediatrician ___________________________________
Phone # ___________________
In the case of an emergency, I give the Tiburon Peninsula Club permission to provide emergency care
for my child.
________________________________________
_____________
Signature
Date