USTA, Medical & Publicity Release Form
2013 USTA National Doubles Championships
USTA, Medical & Publicity Release Form The USTA requires a signed USTA Release and Medical Release to participate in the USTA National Doubles Championships. The Publicity Release is optional. Please complete this form, have it signed by the player and parent or guardian and take the signed form with you to the USTA National Doubles Championships. The signed form must be presented at Registration prior to participating in the tournament. The form may also be faxed to (408) 638-0933. This PDF form has been set up to allow you to type in all information other than the required signatures using Adobe Acrobat Reader, Adobe Acrobat, or Apple Preview. If using Adobe Acrobat Reader, the typed information will not be saved when the document is closed; be sure to print before closing the document. Name:
Event : B16
B14
G16
G14
Address, City, State & Zip Code: Home Phone: USTA Section:
Parent/Guardian Phone: USTA Membership Number::
Exp. Date:
USTA RELEASE: The USTA requires a signed release covering all entrants in national USTA events. The release must be signed by the entrant and parent or guardian of any entrant who is a minor. Acceptance of my entry in these events is without assumption or responsibility of any kind by the USTA, its sectional associates, committee or the management of any event in which I may be entered or may participate. In consideration of the acceptance of my entry, I do hereby for and on behalf of myself, and my heirs and my legal representatives release and forever discharge the USTA, its officers, committees, and representatives and their successors and assigns, of and from any and all claims and damages, losses or injuries which may be suffered or sustained by me in connection with my activities during the period for which such permission is granted and any period traveling to and from the events described, and all claims are hereby waived and released, and I covenant not to sue therefor. Player Signature: Date:
Parent/Guardian Signature: Address, City, State, Zip Code:
MEDICAL RELEASE: I hereby consent to the rendering of emergency first aid and other medical procedures which at the time of injury or illness seems reasonably advisable. I further understand that I will be responsible for payment of any such medical procedures. In consideration of the acceptance of my entry, I hereby agree to abide by all applicable rules and regulations and codes of the USTA and/or the same as may be adopted by the USTA for this USTA National Junior Championship, and hereby consent to be tested for drugs pursuant to the provisions thereof. Player Signature: Date:
Parent/Guardian Signature: Address, City, State, Zip Code:
PUBLICITY RELEASE: I hereby give consent to the USTA to be photographed or filmed in connection with my participation in the USTA National Doubles Championships and agree that the USTA will own any and all rights in such photography and film (herein after referred to as “Footage”). This will permit the USTA to proceed with taking such Footage and I now waive, as to the USTA and its successors, assigns and licensees, all personal rights and objections to any use to be made of my name, likeness, voice or personality in connection with the use of the Footage in any media for any and all purposes, including trade, advertising and promotional purposes, in perpetuity and without further compensation. I understand that in proceeding with filming and photography of the Footage, the USTA will do so in full reliance on the foregoing permission. Player Signature: Date:
Parent/Guardian Signature: Address, City, State, Zip Code:
USTA, Medical & Publicity Release Form The USTA requires a signed USTA Release and Medical Release to participate in the USTA National Doubles Championships. The Publicity Release is optional. Please complete this form, have it signed by the player and parent or guardian and take the signed form with you to the USTA National Doubles Championships. The signed form must be presented at Registration prior to participating in the tournament. The form may also be faxed to (408) 638-0933. This PDF form has been set up to allow you to type in all information other than the required signatures using Adobe Acrobat Reader, Adobe Acrobat, or Apple Preview. If using Adobe Acrobat Reader, the typed information will not be saved when the document is closed; be sure to print before closing the document. Name:
Event : B16
B14
G16
G14
Address, City, State & Zip Code: Home Phone: USTA Section:
Parent/Guardian Phone: USTA Membership Number::
Exp. Date:
USTA RELEASE: The USTA requires a signed release covering all entrants in national USTA events. The release must be signed by the entrant and parent or guardian of any entrant who is a minor. Acceptance of my entry in these events is without assumption or responsibility of any kind by the USTA, its sectional associates, committee or the management of any event in which I may be entered or may participate. In consideration of the acceptance of my entry, I do hereby for and on behalf of myself, and my heirs and my legal representatives release and forever discharge the USTA, its officers, committees, and representatives and their successors and assigns, of and from any and all claims and damages, losses or injuries which may be suffered or sustained by me in connection with my activities during the period for which such permission is granted and any period traveling to and from the events described, and all claims are hereby waived and released, and I covenant not to sue therefor. Player Signature: Date:
Parent/Guardian Signature: Address, City, State, Zip Code:
MEDICAL RELEASE: I hereby consent to the rendering of emergency first aid and other medical procedures which at the time of injury or illness seems reasonably advisable. I further understand that I will be responsible for payment of any such medical procedures. In consideration of the acceptance of my entry, I hereby agree to abide by all applicable rules and regulations and codes of the USTA and/or the same as may be adopted by the USTA for this USTA National Junior Championship, and hereby consent to be tested for drugs pursuant to the provisions thereof. Player Signature: Date:
Parent/Guardian Signature: Address, City, State, Zip Code:
PUBLICITY RELEASE: I hereby give consent to the USTA to be photographed or filmed in connection with my participation in the USTA National Doubles Championships and agree that the USTA will own any and all rights in such photography and film (herein after referred to as “Footage”). This will permit the USTA to proceed with taking such Footage and I now waive, as to the USTA and its successors, assigns and licensees, all personal rights and objections to any use to be made of my name, likeness, voice or personality in connection with the use of the Footage in any media for any and all purposes, including trade, advertising and promotional purposes, in perpetuity and without further compensation. I understand that in proceeding with filming and photography of the Footage, the USTA will do so in full reliance on the foregoing permission. Player Signature: Date:
Parent/Guardian Signature: Address, City, State, Zip Code:
