USPTA Junior Circuit
Secure Entry Form
PLAYER INFORMATION
Full Name:
Address:
City, State, Zip Code:
Home Phone:    Mobile Phone:
E-Mail Address:
Birthday:
Event: & Under
TOURNAMENT INFORMATION

Select the check box below.
Online entries will be accepted as long as the check box appears.

$150.00/player
$100.00/chaperone

Sept 17-19  USPTA State Playoff
Sept 17-19  Chaperone
CREDIT CARD HOLDER INFORMATION
First Name: Last Name:
Address:
City: State: Zip:
Phone Number:
 
E-Mail Address:
Medical Release:  I hereby consent to emergency medical and/or hospital service that may be rendered by or at accredited hospitals by appointed physicians in the event such need arises in the opinion of a duly licensed physician.
 Waiver and Indemnity Agreement:  Acceptance of my entry in these events is without responsibility of any kind by the tournament or any entity sponsoring the event. I do hereby for and on behalf of my heirs and legal representatives RELEASE and forever discharge the tournament, officers and representatives, the sponsoring entities, or by third parties, which injuries may be in any way related to my activities during these events and any period traveling to and from the events described and all such claims are hereby waived and released and covenant not to sue therefore.

By clicking the Submit button you agree that you have read
and understand the foregoing release and indemnity agreement.