After School Programs Registration Form
This is a registration form for the Loudoun County Tennis Academy After School Program
The best choice for your child's after school care
Child's full name *
Your answer
Child's birthdate *
MM
/
DD
/
YYYY
Child's school *
School Grade: *
Does your child require a pick up from school? *
Attendance Period *
Attendance - days per week *
Required
Days of attendance *
Desired Weeks in Fall *
Desired Weeks in Spring *
#1 Parent's (mother or father)/Guardian's full name: *
Your answer
#1 Parent's (mother or father)/Guardian's phone number (please provide cell phone number, work phone number and home phone number): *
Your answer
#1 Parent's (mother or father)/Guardian's e-mail address: *
Your answer
#2 Parent's (mother or father)/Guardian's full name (different than #1):
Your answer
#2 Parent's (mother or father)/Guardian's phone number (please provide cell phone number, work phone number and home phone number, different than #1):
Your answer
#2 Parent's (mother or father)/Guardian's e-mail address (different than #1):
Your answer
E-mail address for contact (please list an e-mail address that we can contact for information and updates, if different than the e-mail address provided at the beginning of this form)
Your answer
Have your child ever participated in one of the Loudoun County or Luis Rosado Tennis Academy programs before? *
MEDICAL RELEASE FORM
In case of emergency contact (please provide full name, phone number, e-mail address and residency address): *
Your answer
Child's allergies (please list all allergies, including medical substances/medicines. Do not leave this question blank - for no allergies, write NONE): *
Your answer
Medical/Physical conditions (please list all diseases, syndroms and/or special conditions the child may have; Do not leave this question blank - for no medical/physical conditions, write NONE): *
Your answer
Medical Insurance Information (name your insurance company and policy/group ID number): *
Your answer
Family's Physician contact (please provide full name and phone number): *
Your answer
Release and discharge agreement
By submiting this form you agree with the medical release form and forever discharge Loudoun County Tennis Academy
and any of its employees or representatives from any and all claims, demands, actions or cause of action, past, present or future arising out of any damage or inquiry while participating in this program.
Payment Policy
Payment will be done by check on the first day of attendance. Please, make the check payable to LOUDOUN COUNTY TENNIS ACADEMY.

First Week is FREE

Cost / week:
5 days / week $185
3 days / week $135
2 days / week $110

10 weeks enrollment discounted Cost / week:
5 days / week $179
3 days / week $131
2 days / week $107

22 weeks enrollment discounted Cost / week:
5 days / week $174
3 days / week $127
2 days / week $103

43 weeks enrollment discounted Cost / week:
5 days / week $169
3 days / week $123
2 days / week $100

Refund Policy
No refunds will be done.
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