Athletes Youth Success Institute Tennis Program REGISTRATION FORM
Please complete this application in detail to ensure your program
Email address *
Student #1 First Name *
Your answer
Student #1 Last Name *
Your answer
Student #1 Date of Birth *
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DD
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YYYY
Student #1 Age *
Your answer
Has your schoolar played tennis before? *
Student Grade Level *
Student #1 Medical Restrictions and Previous Injuries: List ALL previous injuries, allergies, prescribed medications, behavior disorders, learning disabilities, or medical diagnosis. Please be detailed so that we can best assist your scholar. *
Your answer
Student #2 First Name (Sibling) *
Your answer
Student #2 Last Name *
Your answer
Student #2 Age *
Your answer
Has Student #2 played tennis before? *
Student #2 Date of Birth
MM
/
DD
/
YYYY
Student #2 Grade Level *
Student #2 Medical Restrictions and Previous Injuries: List ALL previous injuries, allergies, prescribed medications, behavior disorders, learning disabilities, or medical diagnosis. Please be detailed so that we can best assist your scholar. Medical Needs/Restrictions: List ALL allergies, prescribed medications, behavior disorders, learning disabilities, or medical diagnosis. Please be detailed so that we can best assist your scholar.
Your answer
Mailing Address *
Your answer
Check box if legal restrictions or custody orders apply (please note this information will be used for the dismissal process) *
Required
Parent/Guardian First & Last Name *
Your answer
Parent/Guardian Email Address *
Your answer
Contact Number *
Your answer
#1 Emergency Contact First & Last Name (this name will be added to your scholar's authorized pick up list) *
Your answer
Relation to child *
Your answer
Phone Number *
Your answer
#2 Emergency Contact First & Last Name (this name will be added to your scholar's authorized pick up list) *
Your answer
Phone Number *
Your answer
#3 Emergency Contact First & Last Name (this name will be added to your scholar's authorized pick up list)
Your answer
Primary Phone Number
Your answer
#4 Emergency Contact First & Last Name (this name will be added to your scholar's authorized pick up list)
Your answer
Primary Phone Number
Your answer
I agree to the expectation AYSI. I understand students who refuse to follow the safety procedures and expectations will not be allowed to continue in the program.
If a medical emergency arises, program staff will take all steps necessary to ensure the safety of the participant and will call, if necessary, a public emergency vehicle for transport to an emergency facility. I understand that I will be responsible for any transportation charges and medical expenses incurred. *
Required
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