Membership Application
Please print below.

Date : ______________________

Name : _________________________________________

Address : __________________________________________

City, State, ZIP : ______________________________________

Phone : _____________________________________

Date of Birth : __________________

Play Experience Level (circle):....1....2....3....4....(4 being very experienced)

Amount Enclosed : $ ________________

Signature(s):_________________________________________

(NOTE: IF YOU ARE UNDER 18 YEARS OLD, A PARENT MUST SIGN ABOVE ALSO)

Liability Waiver

"I waive all liability responsibilities from the Village of Sherburne NY for my play in their Municipal Building as a member or guest of The Chenango Valley Table Tennis Club. I will not hold the Village of Sherburne NY or The Chenango Valley Table Tennis Club liable for any personal injury, damage to, or loss of, personal property while playing on their property. I play at my own risk."

Signature(s):_________________________________________

(NOTE: IF YOU ARE UNDER 18 YEARS OLD, A PARENT MUST SIGN ABOVE ALSO)