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

Date of Birth (required): (mm/dd/yyyy)

Gender: ---MaleFemale Ability: ---Never PlayedBeginnerAdv BeginnerIntermediateAdv IntermediateAdvanced

Street Address:

City: State: ZIP:

Email (required): Home Phone:

Work Phone: Cell Phone:

Select Day(s):
($60/day): 9:00 am - 12:30 pm
 Wed Dec 26 Thurs Dec 27 Fri Dec 28

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 a Junior Participant (Jr.) at his or her sole risk, and the Club shall not be liable for any injuries or damage to any Jr. or guest, or the property of any Jr., 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 Jr’s 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 Jr. by another Jr. is the sole responsibility of the offending Jr’s parent or guardian.

Signed: Date:

Above named Parent or Guardian agrees to the Liability Waiver with this electronic signature.

EMERGENCY CONTACT: EMERGENCY PHONE: