First Name (required):     Last Name (required):

Email (required): Home Phone:

Work Phone: Cell Phone:

Birthdate (dd/mm/yyyy):

Gender:  Male Female

Ability: ---Beginner (2.0)Adv. Beginner (2.5)Intermediate (3.0)Adv. Intermediate (3.5)Advanced (4.0+)

Street Address:
City: State: Zip Code:

Program: ---Breakfast ClubAdult StarterAdult WorkshopSingles DrillTeam DrillDrill & Kill
Day: ---MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Start time:

 Second Choice Second Clinic
Program: ---Breakfast ClubAdult StarterAdult WorkshopSingles DrillTeam DrillDrill & Kill
Day: ---MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Start time:

Notes:

Membership: ---Family MembershipAdult MembershipJunior Membership Status: ---Current MemberTime to RenewNew Member

Liability Waiver
It is expressly agreed that all use of the Tennis and/or Fitness Facilities and/or Pool at Nassau Racquet & Tennis Club (“the Club”) shall be undertaken by an Adult Participant (“Participant”) at his or her sole risk, and the Club shall not be liable for any injuries or damage to any Participant or guest, or the property of any Participant, or be subject to any claim, demand, injury or damages whatsoever, including, without any limitation, those damages resulting from acts of active or passive negligence on the part of the Club, its successors or assigns, as well as its officers and agents, for all such claims, demands, injuries, damages, actions or causes of actions. It is specifically agreed that the Club shall not be responsible or liable to Participants for articles or property lost or stolen in the Club. It is also agreed that any damages to the Club facilities or property or to the property of any Participant by another Participant is the sole responsibility of the offending Participant.

Signed (Required): Date:

Above named Adult Participant agrees to the Liability Waiver with this electronic signature.

EMERGENCY CONTACT: EMERGENCY PHONE: