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BILL CLARK TENNIS ACADEMY REGISTRATION

Please fill out the entire form for correct registration!

Name
Address
City
State
Zip Code
Email Address
Home Phone
Alternate Phone (cell)
Age/Birth Date
Emergency Contact Name
Emergency Contact Relationship
   
Program
Class
JCC Member
Requested Session Dates/
or Additional Information
Allergies
Insurance Information
Insurance Policy Number

General Release:
 

The undersigned Participant and/or his/her guardian, inconsideration for the City of Cooper City and the Cooper City Parks & Recreation Department providing facilities, instruction, and supervision in the activity for which he/she has registered does hereby:
 
1. Assume all risks and responsibilities of possible damage or injury involved through participation in said activity. I understand that I am to furnish my own insurance.
 
2. Agree to indemnify and hold harmless the City and/or its departments or agents from liability resulting from my participation in said activity.
 
I accept this Agreement

Parents must type their name for electronic signature