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QUAD CITIES NEW YEAR
PICKLEBALL
TOURNAMENT
Indoors at Sports Town, 1700 Blackhawk Trail,
Eldridge, Iowa. Four courts available.
See club website http://qcpickleball.wordpress.com/
Spectators welcome.
Join us for a fun day of pickleball.
8 a.m. to 4 p.m. Friday, Jan. 2, 2015 (Day after New
Year’s Day.) Refreshments provided.
Format is a Round Robin Scrambles/Seed Play.
Each player of an assigned group will play doubles
matches WITH and AGAINST players in their
group. After Round 1 we will seed all players and
play round 2. Then the top scoring individuals will
be bracketed in a playoff tournament for a skill level
championship. Depending on entries, we plan for
Skill Levels 3.5 – 5.0 in the morning and 1.0- 3.0 in
the afternoon. Final start times to be announced.
SKILL LEVEL GAMES
Schedule
Rules of Play
7 a.m. – Group 1 check in and warm up.
1. Players grouped into divisions based on skill
8 a.m. – Morning play begins.
level.
11:30 a.m. – Group 2 check in and warm up.
2. Doubles only.
12:30 p.m. Afternoon play begins.
3. Random draw for partners in Round 1
For more information, contact Doug Michel at 563-388-2371, email: douglas_michel@ml.com
Detach and mail entry and waiver release to our registrar, Judy Petersen at Quad Cities Pickleball Club,
1704 Picadilly Place, Davenport, IA 52807. Registration fee is $17 ($12 for Quad Cities Pickleball Club
Members). Deadline for registration is Friday, Dec. 26, 2014. (Registrations received after Dec. 26 will be
accepted, space permitting.) SELF RATING guidelines available on club website, Skills and Drills Tab.
Entry Form (All Players Required to Register)
Player’s Name _________________________________________________
Address ______________________________________________________
Volunteers
Email ________________________________________________________
If you have a friend or family
member, not competing, that
would like to volunteer, helping
with various tasks for the event,
please enter their name and
phone number. Thanks!!
Your age (as of Dec 31, 2015) ________; Male ________ Female ________
Names: ________________
Playing Skill Level (check one):
_______________________
City, State, Zip _________________________________________________
Phone ______________________ Cell Phone _______________________
_____ Skill Levels 1.0-3.0, or _____ Skill Levels 3.5-5.0
_____________ $17 Entry Fee Each ($12 for Club Members)
_____________ $15 for QC Pickleball Club Membership
_____________ Donation to QC Pickleball Club (not tax deductible)
_____________ Total Enclosed.
Phone: ___________________
Email: ___________________
2014 Holiday Pickleball
Games
Waiver Statement
In consideration for being allowed to participate in any way in the Quad Cities Pickleball Club events and activities, I
__________________________, the undersigned acknowledge and agree that:
(Please Print Your Name)
1. The risk of injury from the activities involved in this program is significant, including the potential for permanent
paralysis and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of
serious injury does exist and,
2. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of
others, and assume full responsibility for my participation and,
3. I willingly agree to comply with the stated and customary terms and conditions for participation, If however, I
observe any unusual significant hazard during my presence or participation, I will remove myself from participation
and bring such to the attention of the nearest official immediately and,
4. I, on behalf of myself and my heirs, assignees, personal representatives, and next of kin, hereby release and hold
harmless Quad Cities Pickleball Club and Lancer Courts, LLC (Sportstown), their officers, agents, and/or
employees, other participants, sponsoring agencies, sponsors, and advertisers, and if applicable, owners, and
lessees of premises used to conduct the event, with respect to any and all injury, disability, death, or loss or
damage to person or property, whether arising from the negligence of the releases or otherwise.
I have read this release of liability and assumption of risk agreement, fully understand its terms, understand that I have
given up substantial rights by signing it, and sign it freely and voluntarily without any inducement.
I agree to the waiver statement
(Yes or No)
Players Name ______________________________________________________ Age _________________________
(Please Print)
Player’s Signature __________________________________________________ Date _________________________
If Player is a Minor
Parent/Legal Guardian: ____________________________________________________________________________
(Please Print)
Parent/Legal Guardian Signature: _______________________________________ Date ________________________
Emergency Info
Doctor
Doctor’s Phone Number
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Will Anyone Accompany You to
the Games?
If yes, Name of Person
Yes or No.
Quad Cities Pickleball Club Membership Application
Why join?
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Print legibly. Fill in all blanks.
We provide a strong voice in the community to
advocate for the sport resulting in courts and places
to play.
We sponsor organized play at multiple venues for
people to come together to enjoy the sport.
We organize and sponsor tournaments and fun
activities in the community.
We keep you informed with a website and social
media.
We offer free lessons for players to learn the
strategy of the game.
You are included under a liability insurance policy for
club-sponsored activities.
Together we are strong.
□ New Application
□ Renewal Application
Membership Type:
□ Individual $15/Year □ Donor $40/Year
Date of Application (mm/dd/year) __________________
Gender:
□ Male □ Female
Applicant Birth Date (mm/dd/year) _________________
Last Name __________________________________________ First Name ___________________________________
Address _________________________________________________________________________________________
City _______________________________________________ State ________________ Zip _____________________
Phone _____________________________________________ Mobile Phone __________________________________
Your e-mail _______________________________________________________________________________________
Emergency Contact: __________________________________ Phone ________________________________________
Please Note: Your contact information is used for club
purposes only. It is not shared with outside
organizations. Members occasionally get e-mail
notification of events and also have access to club
activities and information from the club website.
Memberships in other Organizations: (The USA
Pickleball Association works every day on behalf of all of
us who love this game. You are encouraged to join this
Can Help With:
□ Activities Coordination
□ Safety/Education Events
□ Training – Beginner
□ Training – Intermediate
□Training – Advanced
group in addition to the QC Pickleball Club. See website
for details.)
Check if you are a member of the USA Pickleball
Association or other social clubs:
□ USA Pickleball Association
□ Other (please list) ________________________________
□ Health/Fitness Fairs
□Membership
□ Fall Picnic
□ Winter Picnic
□ News / Photography
□ Web Site
□ Volunteering – QC Senior
Olympics Tournament in June
□ Volunteering – Other
Tournaments
□ Other (specify) __________
* Single adult children up to 22 years old living at their parent’s address may continue on their parent’s membership.
Make checks payable to Quad Cities Pickleball Club.
Mail completed form to QCPC, Attn: Membership, 2895 Central Ave., Bettendorf, IA 52722.
Waiver, Consent and Release of Liability WARNING: READ CAREFULLY. THIS AGREEMENT INCLUDES A RELEASE OF LIABILITY AND WAIVER
OF LEGAL RIGHTS AND DEPRIVES YOU OF THE RIGHT TO SUE THIS ORGANIZATION AND OTHER PARTIES. DO NOT SIGN THIS AGREEMENT UNLESS
YOU HAVE READ IT IN ITS ENTIRETY. SEEK THE ADVICE OF LEGAL COUNSEL IF YOU ARE UNSURE OF ITS EFFECT.
Admission of Risk and Liability Release: In submitting this application, I acknowledge that I am assuming risks, and agreeing to indemnify, not to sue
and release from liability Quad Cities Pickleball Club (QCPC) and Lancer Courts, LLC, its officers, board of directors, members and volunteers, in the
case of any accident, injury, or damage of any kind . I recognize that playing pickleball is potentially dangerous, and I represent that I am a
competent player with safe equipment. I understand that I participate in club activities at my own risk. I further recognize that safety is my
personal responsibility and I agree to participate in keeping all QCPC activities safe as possible. I agree to hold the club and facility harmless and
indemnify either for all costs, judgments and awards that may be claimed including the cost to defend such claims brought by you or another in
your behalf or that of others.
FOR MINORS: Parent or Guardian must agree to this waiver:
I am the parent or guardian of the above listed Applicant, and assure QCPC that the facts and responsibilities listed above concerning my child or
ward are true. By signing this form I am giving my permission for my child or ward to participate in QCPC events and activities. I agree to the terms
of the above listed Admission of Risk and Liability Release whose terms bind me, my child, my heirs, legal representatives and assignees.
If you are older than thirteen, but not yet eighteen or you are incapacitated and/or mentally challenged, please have a parent or legal guardian
note their acceptance of the terms of registration by providing their initials where indicated below. If you are at least eighteen, please enter your
own initials where indicated below. I understand that this Waiver and Release may be stored electronically and agree that a copy is authentic and
admissible as evidence in any future dispute or proceedings. I have read, understood, and accept the agreement above. My submission of this form
shall act as my legal signature.
Initials of: _____ registrant if over 18 years of age; or parent/legal guardian of minor, incapacitated, or mentally
challenged person.
Liability Release - Signature Required
Individual Membership (self) _______________________________ Date _________________
Parent/Guardian for Child <18 __________________________ Date _____________________