RAJEEV RAM FOUNDATION GRANT

DEADLINE: September 15th




Applicant Information:

Name of Youth Applicant*
US Citizen*
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Date of Birth*
Years Old
People
Parent/Guardian’s Name*
Address*

Tennis Experience:

Do you play USTA tournaments?*
Do you play middle school tennis?*
Please Indicate whether you have participated in any of the following events, tournaments, and/or programs:*

Purpose for Funding Request:

Funding Sources:

$
$
$
$
$
$

Applicant Questions

(to be answered by applicant)

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Use your mouse or finger to draw your signature above
Date*

USTA/MIDWEST TENNIS & EDUCATION FOUNDATION, INC. AUTHORIZATION FOR USE OF NAME AND IMAGE

I do permit and authorize USTA/Midwest Tennis & Education Foundation, Inc. (USTA/MTEF) and its employees, agents, publishers, and personnel (“Authorized Parties”) who are acting on behalf of USTA/MTEF to use my name and image for purposes related to the educational and philanthropic mission of the USTA/MTEF, including publicity, marketing, and promotion of USTA/MTEF and its various programs without compensation to me.  I understand my image may be copied and distributed by means of various media, whether now known or hereafter devised, including but not limited to photographs, video presentations, brochures, placement on USTA/MTEF websites, digital form,  newspapers or other publications, or other print and electronic media.  My image shall include photographs that I provide to USTA/MTEF, as well as photographs that may be taken by USTA/MTEF.  I waive any right to inspect or approve the finished product or any material in which USTA/MTEF may eventually use my name or image.

I understand that although USTA/MTEF will endeavor to use my name and image in accordance with standards of good judgment, USTA/MTEF cannot warrant or guarantee that any further dissemination of my name and image will be subject to USTA/MTEF supervision or control.  Accordingly, I release USTA/MTEF and the Authorized Parties from any and all claims and liabilities related to dissemination of my name and image.

This Authorization for Use of Name and Image is effective the date set forth below and shall be binding on my heirs, successors, assigns, and legal representatives, and shall inure to the benefit of the legal representatives, successors, and assigns of USTA/MTEF.

This Authorization for Use of Name and image shall be governed by the laws of the State of Indiana, may not be amended except in writing signed by both parties, and constitutes the entire agreement between me and USTA/MTEF with respect to the subject matter contained herein.

I have read this document and understand its contents.

Applicant

Name*
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Date*

CONSENT OF PARENT/LEGAL GUARDIAN REQUIRED IF ABOVE INDIVIDUAL IS A MINOR

I am the parent and/or legal guardian of the above minor and hereby consent and agree to the foregoing terms and provisions on his or her behalf.

Name*
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Date*