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ENROLLMENT INSTRUCTIONS: Please use the online enrollment form to enroll with the academy, select your classes and make payments. You can also download this enrollment form and submit it along with a check at the Bill Clark Tennis Academy administrative office. Registration Form
  General   |
  Medical Info   |
  Classes   |
  Payment   

| Student Information
Full Name

Date of Birth
   
Social Security Number
- -
Gender

Email

Mobile Phone
() -
Phone
() -
Home Address

City

State

Zip

School

Grade
| Tennis Information
Previous Academy

Previous Club

Days Played

Level

Years Played

Age Played

USTA Years Played
| Mother's Information
Full Name

Mobile Phone
() -
Business Phone
() -
Email

Business Address

City

State

Zip

| Father's Information
Full Name

Mobile Phone
() -
Business Phone
() -
Email

Business Address

City

State

Zip

| Emergency Contact
Full Name

Mobile Phone
() -
Business Phone
() -
Email

Relationship


Full Name

Date of Birth
   
Gender

Height

Weight

Blood Type

Has the athlete had any of the following?
Asthma
Chicken Pox
Diabetes
German Measles
High Blood Pressure
Measles
Mumps
Pneumonia
Allergies
Hay Fever
Asthma
Eczema
Insect Stings
Food Alergies

Other (list below)

Drug Reactions
Sulpha
Penisilin
Antibiotics
Other (list below)

Is the player taking medication during training?
Yes No
If yes, please name of drug and dosage:

Is there any medical condition or history wich required special attention?
Yes no
If yes, please explain:

Name of Primary Care Physician

Phone Number
() -
Address

City

State

Zip

Facility / Clinic

Facility Phone

Other Contact Info

Insurance Provider

Insurance Policy Number

Policy Holder Name

Insurance Phone

Policy Expiration Date
   

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