Town of Mamaroneck / SPORTIME Harbor Island Scholarship Form

HARBOR ISLAND

P.O. Box 783, Mamaroneck, NY 10543
914-777-5050

CONTACT CLUB

APPLICANT INFORMATION

First Name *

Last Name *

Date Of Birth *

Gender *

Male Female

PARENT / GUARDIAN INFORMATION

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Email *

Parent/Guardian Confirm Email *

Parent/Guardian Mobile Phone * Required Format: US - (555) 555-5555

Parent/Guardian Home Phone Required Format: US - (555) 555-5555

APPLICANT HOME ADDRESS

Street Address *

Street Address Line 2

Postal / Zip Code *

Country *

ADDITIONAL INFORMATION

Applicant T-Shirt Size *

S M L XL

Parent/Guardian T-Shirt Size *

S M L XL

BACKGROUND INFORMATION

Have you ever participated in tennis programs and/or lessons? *

Yes No

If yes, where? *

For how long? *

Are you currently participating in tennis programs and/or lessons? *

Yes No

If yes, where? *

Number of days/hours a week? *

Are you involved in extracurricular and/or volunteer activities? *

Yes No

What do you want to be when you grow up?

Why do you want to play tennis at SPORTIME Harbor Island? *

FINANCIAL INFORMATION

ASSUMPTION OF RISK AND RELEASE: ALL FINANCIAL INFORMATION PROVIDED WILL BE KEPT STRICTLY CONFIDENTIAL. PLEASE READ:

The undersigned hereby authorizes SPORTIME Clubs, LLC d/b/a SPORTIME, to verify parent/guardian employment and income history, and related information. The information contained in this form, and any information procured pursuant to verification, will be kept confidential. It will be utilized by SPORTIME solely for the purposes of determining nominee's eligibility for a SPORTIME Harbor Island Scholarship. SPORTIME will not use such information for any other purpose. By signing and submitting this form, I agree that I am the parent or legal guardian of the above named participant and that we will abide by all rules and regulations which now exist or which may be hereafter adopted or amended by SPORTIME Clubs, LLC.

I agree to these terms *

By clicking submit, you acknowledge that all information is true and correct.

SPORTIME HARBOR ISLAND SCHOLARSHIP APPLICATION

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