I, hereby, for myself, my heirs executors and administrators, waive/release any claims for damages that I may have against the Dayton Squash Center and its employees, for any and all injuries which may be suffered by me in connection with my competition in said tournament.

Name:_______________________________________________________________________

Address:_____________________________________________________________________

City:_____________________________ State:_______________ Zip:___________________

Phone: (H)__________________________ (W)______________________________________

Email address: ________________________________________

Birth Date:____________________ USSRA #____________________

1st Division _________________  2nd Division___________________

Will be attending the saturday night party  ___YES ___NO

# of people______($20.00 per guest)

Check enclosed for total of $___________________(Payable to Dayton Squash Center)