Last Name:

Last Name:

First Name:

First Name:

Address:

Address:

City:

City:

State & Zip Code:

State & Zip Code:

Date of Birth:

Date of Birth:

Tel. No.

Tel. No.

Email:

Email:

ATA No. & Expiration Date:

ATA No. & Expiration Date:

ATA Membership Fee for Non-Members: $15.00

AMOUNT ENCLOSED:

NOVICE SINGLES - $20.00

LEVEL 2 SINGLES - $20.00

BOYS

GIRLS

BOYS

GIRLS

• 12

• 12

• 12

• 12

• 14

• 14

• 14

• 14

• 16

• 16

• 16

• 16

• 18

• 18

• 18

• 18

DOUBLES - $30.00 PER TEAM

BOYS

GIRLS

• 12

• 16

• 12

• 16

• 14

• 18

• 14

• 18

I understand that acceptance of my entry is without assumption of responsibility of any kind by the NYTA, CITY OF NEW YORK, NEW YORK CITY DEPARTMENT OF PARKS AND RECREATION , FRED JOHNSON PARK, SPONSORS/AGENTS OF ANY EVENTS: In consideration of the acceptance of my entry, I do forever release and discharge the aforementioned from and all claims, demands of any kind, which may be suffered and sustained by me in connection with my activities during the period for which such permission is granted and the period traveling to and from this event described, and all claims are hereby waived and released, and I promise not to sue.

Signature: Date: