Usrtf Form303 Lh
- 1. REQUEST FOR RINGTENNIS SPECIALIZED SPORTS TRAINING (See Private Act Statement on reverse) This form may be forwarded as E-mail attachment, appropriate E-mail forwarding information for membership will be considered substitute for signatures. Please, make your check or money order payable to TIDC for $75.00 to retain a spot on the roster. The $75 application fee is NON REFUNDABLE. The fee is paid in good faith to retain a spot for scrimmage purpose ONLY, Return the application to: TIDC, P.O.BOX 252647., West Bloomfield, Michigan 48322-3420 US. Please, attach two recent passport size photos to process your application. Please consider me for participation in USARTF/WTF-level sports activities in: RINGTENNIS IN KOBLENZ, GERMANY 2010 US TEAM SPORT POSITION/DIVISION COMPETITION (USARTF, WTF, or others) DATES OF COMPETITION 10000111 I. PERSONAL DATA NAME (Last, First, Middle initial) GRADE SEX SOCIAL SECURITY NUMBER UNIT UNIT ADDRESS BASE DATE OF BIRTH (YYYYMMDD) PLACE OF BIRTH (City, State, Country) U.S. CITIZEN (By birth or PASSPORT NO. & EXP. DATE naturalization) (If issued) WEIGHT HEIGHT MARITAL STATUS ATHLETIC UNIFORM SIZES (Married or Single) WARM UPS: T-SHIRTS: SHORTS: POLO: PERMANENT HOME ADDRESS (Street, City, State, & Zip Code) PRESENT HOME ADDRESS (Street, City, State, & Zip Code) HOME TELEPHONE (Include area code) HOMETOWN NEWSPAPER (Name and address to include zip code) HOME E-MAIL ADDRESS II. MILITARY DATA DUTY TITLE AFSC FLYING STATUS TIME ON PENDING DATE OF (Yes or No) STATION PCS/TDY SEPARATION III. SPORTS EXPERIENCE (List experience for sport applied for only) LOCATION SPORT DATES OF AWARDS RECEIVED/NOTEABLE ACCOMPLISHMENTS COMPETITION HIGH SCHOOL COLLEGE CIVILIAN MILITARY IV. SIGNIFICANT PERFORMANCE FOR PAST 3 YEARS EVENT LOCATION DATE RESULTS (Times, finish, totals, etc.)
- 2. V. REMARKS AND REFERENCES (if more space is required, use bond paper and attach.) VI. ATHLETES SIGNATURE BLOCK ATHLETE TYPED NAME SIGNATURE CELL PHONE DATE WORK E-MAIL ADDRESS VII. PARENT’S ENDORSEMENT BLOCK (IF A MINOR) PARENT/GUARDIAN TYPED NAME SIGNATURE CELL PHONE DATE WORK E-MAIL ADDRESS VIII. MEDICAL INSURANCE BLOCK (REQUIRED) INSURANCE COMPANY: TYPED NAME POLICY # PHONE EXPIRATION DATE ADDRESS:
- 3. Application for specialized training is ____ Approved ____ Disapproved contingent upon current workload and manning. (Place an “X” in the appropriate blank.) I understand that this individual may be selected for higher-level competition and that RINGTENNIS CLUB is authorized to extend his/her orders. 487-1112 IX. MANAGER ENDORSEMENT BLOCK (This block applies to World Class Athlete Program applicants only) CLUB MANAGER TYPED NAME SIGNATURE CELL PHONE DATE WORK E-MAIL ADDRESS Request for release to participate in specialized training is ____ Approved ____ Disapproved. (Place an “X” in the appropriate blank.) X. MEDICAL CLEARANCE BLOCK N DOCTOR’S/PHYSCIAN’S ENDORSEMENT NAME: I certify that the statement contained in this application is true and exact to the best of my knowledge. This individual has displayed sufficient competence/skill to compete in the sport of __________RINGTENNIS_________ at USARTF or higher level. (List name of sport) EMAIL ADDRESS: SIGNATURE PHONE DATE XI. MANAGEMENT ENDORSEMENT I have reviewed this application and recommend approval for USARTF or higher-level competition. Make check or money order FROM TYPED NAME AND SIGNATURE OF REPRESENTATIVE DATE Payable to: TIDC P.O.BOX 252647 West Bloomfield, MI. 48322 WORK E-MAIL ADDRESS US PRIVACY ACT STATEMENT: AUTHORITY: 10 U.S.A.R.T.F... 8013 and EO 9397. PRINCIPAL PURPOSES: To assist in the identification of individuals applying for participation in USARTF training, to determine those qualified for such training and for use in the administration of specialized training programs. ROUTINE USES: To administer specialized training programs. Information on this form, including the SSN, is used to identify individuals desiring specialized training. Information furnished may be disclosed to WTF component or any part thereof, and upon request, to other Federal, State, and local government agencies in the pursuit of their official duties. Information may be released to the United States Amateur Athletic Union, United States Olympic Committee, and to the news media for publicity purposes. It may also be used for other lawful purposes including law enforcement and /or litigation. DISCLOSURE IS VOLUNTARY: Failure to provide the information, including the SSN, precludes the individual from consideration for USARTF sports training.