FAIRFAX COUNTY GOLDEN RACQUETS TENNIS CLUB MEMBERSHIP APPLICATION

Please print out this form, fill it in and mail

(with $20 check payable to Fairfax County Golden Racquets) to:

Joan Linthicum 40651 Lenah Run Circle  Aldie, VA 20105-2361

_________________________________________________ Birthdate____/___/_____

Last Name                   First        Middle          (Call me)

 _____________________________________________________________________

Street Address                                        City                                Zip Code

Phone:  (___) __________ Cell phone:  (___)___________E-mail:________________________

Tennis Rating __________

NPR within past 3 years:  Certificate provided (  ) Golden Racquets Qualification Committee (   ) (GR provides)

In case of emergency notify:

___________________________________________________ Phone: (___)_____________

Name                      Relationship

___________________________ Phone:  (___)______________

Name of Physician

Over

 IMPORTANT – PLEASE READ AND SIGN

Under Virginia Law, Fairfax County and its departments are immune to suits based on tortuous injury and, to a lesser intent, its employees are also covered by this immunity.  Participants are advised to carry their own insurance when participating in recreation department programs.

 Participants in Golden Racquets tennis, who are required to perform strenuous physical activity, should be capable to do so.  Participants are advised to carry their own insurance while participating in Golden Racquets.  It is also recommended that a doctor’s approval be obtained prior to becoming actively involved.

Release:

I, the undersigned, verify that I am not under medical care that would prevent my participation in Golden Racquets; further I am a voluntary participant and as such, I assume all risks related to Golden Racquets and its officers and agents.

 Signature of Participant:________________________________________Date:_____________

Tennis Experience/Preferences Survey

EXPERIENCE

1. How long have you been playing tennis _______Yrs
2. Has the tennis been mostly ____ Singles or _____ Doubles
3. How often have you played in the last year

_____ Times per Week _____   or Month _____

4. Have you ever played in a league Yes___ No___
   1. If so, was it singles ___ or  Doubles ___
5. Do you have a USTA Rating Yes___ No___
   1. If so, what is the rating ____ 
   2. When was the rating given ___________ mmddyy

PREFERENCES

6. How many times a week would you like to play ____ times.
7. What days during the week would you prefer to play

                        Mon___ Tues___ Wed___ thu___ Fri___ Sat___ Sun ___

8. What time of day would you prefer to play

                        Morning___ Afternoon___ Evening___

9. Would you be interested in Subbing periodically
   1. If so, how often weekly ____ times
10. In the summer, would you prefer to play indoors___ or outdoors___
11. In the Winter, would you prefer to play indoors___ or outdoors___