(1)  PERSONAL INFORMATION (remains confidential)

First Name:    Last Name:   Date of Birth: Gender: Male Female

Address:   City: Southbury Danbury Brookfield _ Middlebury Oxford Woodbury Washington Newtown Roxbury Other State: Zip Code:

Phone :  Work:  Home:  Cell:  Email:

(2)  LEVEL OF PLAY

 U.S.T.A Rating : 2.5 _ Not sure 3.0 3.5 4.0 4.5 5.0       Ranked : yes  (what nr & division)   no   

: Playing history :

(3)  EVENT

Category:           men's singles  women's singles men's doubles women's doubles mixed doubles

senior singlessenior doubles senior mixed junior singles junior doubles  junior mixed

Doubles Partner:

(4)  PAYMENT

CHECK   (made out to Val Stoiana)                  CREDIT CARD

after you submit you'll be taken to the payment page