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Chapter/Program Name:___ ID #: ________

Date of Submission:_____________ Calendar Year Covered:_____

New USA Tennis NJTL Chapter or Program q Existing Tennis program new to USA Tennis NJTL q

All programs and chapters must submit to their USTA Section office a fully completed registration once every four years. For three years following a full submission, programs or chapters may complete the Affidavit of No Change below in lieu of submitting the full report if there are no significant changes, (i.e.: a new full report needs to be done every four years; e.g. 1999, 2003, 2007, etc.). Chapters, however, must attach their latest financial report (section 4(E)) and current list of directors and officers (Section 4(F)) with the Affidavit of No Change.

===================================================================================

Affidavit of No Change

Organization Name:_______ ID #: ________

Address:_____ City:_____________ State:_________ Zip:__________

Telephone: (___)_____________ Fax: (___ )_____________ Email:_________________

I,_________________ ,__________________ ,___________________________

Name Title Organization

affirm that our last registration was submitted for the year _______ on _______ and that since the above date nothing has occurred which changed in any significant way any response to that registration.

Name:_______________________ Title:____________________________

Signature:____________________________________________________

Sworn to before me this _______ day of _______, 20___

Notary Public


1. Individual Name:____________________________________________

Telephone: (____)__________ Fax: (____)__________ Email:______________

2. Organization Name:________________________________________________

Mailing Address:___________________________________________________

City:__________________ State:__________ Zip:_________________

Shipping Address (No PO Boxes Please):_______________________________

City:__________ State:__________ Zip:______

Telephone: (___)__________ Fax: (___)__________ Email:_______________

President:__________________ Executive Director:_____________________

3. Type of Community being served: q City q Suburbs q Rural Area

4. Application for: q Program Status q Chapter Status

If program, please proceed to questions 5 to 25. If this is your first season, please answer only those questions relating to a start-up program. If Chapter, please provide the following additional information

a. Are you requesting an exclusive territory? q Yes q No. If yes, please clearly describe its boundaries: If you need more space please attach additional pages. Where possible please try to tie in to county, city, town, or village boundaries. For example, “City of Stockton, California”.

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

b. To the best of your knowledge, is there another USA Tennis NJTL Chapter or Program within the territory you have requested? If so, please provide their name and address.

________________________________________________________________

________________________________________________________________

c. Date of incorporation: ___________________

d. Has organization received 501©3 status? q Yes q No If yes, enter date:________________

e. If operating for more than 1 year, please provide a copy of your last financial report (annual report prepared by an independent certified public accountant, or Federal Form 990 filed with IRS, or financial report certified by a practicing attorney, or copy of the annual filing with the state agency responsible for supervision of charities.)

f. Please attach a current list of your Board of Directors and Officers with their names, address and work/or home phone number, fax and email address to the extent they are available.


Participant Statistics

The gender, ethnic, and economic information is very helpful, but not essential. It may be estimated. The total number of participants is essential. It also may be estimated. If possible, base the number of participants on registration cards counting one person once per year.

5a. Total number of participants in program: _____________ Is this an

q estimate or q accurate figure?

5b. Number of participants: ______5-9 years old ______10-13 years old ______14-18 years old

5c. Please enter demographic breakdown of participants below (NO percentages please):

Participant Information

African American

Asian American

Caucasian

Latino American

Native American

Other

Total

# of male participants

# of female participants

6. The average family income range of participants is:

Less than $30,000 More than $30,000

Program Information

7a. Types of tennis programs provided:

(check all that apply)

q USA Tennis 1-2-3 q USA School Tennis

q USA Team Tennis q After Schools Tennis

q Sanctioned Tournaments

7b. Types of Educational Components

(check all that apply)

q Mentoring q Reading Club q Tutorial

q Alcohol &Drug q Health & Nutrition

q College/High School Preparation & Guidance

q Other :_____________________________________

8. In which of the following seasons do you have official USA Tennis NJTL programming?

(check all that apply)

q Spring-# of weeks:____ q Summer-# of weeks:____ q Autumn-# of weeks:____ q Winter-# of weeks:_________________________________

9. Please enter site information in table below:

Parks & Recs

Public School Courts

Private

Commercial Courts

Private

Non Profit

Other

Total

# of sites used for program

# of courts used for program

10. Average number of USA Tennis NJTL program hours per week, per site:____________

11. Does chapter/program charge a participant fee? q YES q NO If yes, how much (per season)? _____

12. Does chapter/program provide scholarships? q YES q NO

If yes, how many? _________

13. Does chapter/program provide team shirts? q YES q NO

14. Does chapter/program have racquets available for participant use? q YES q NO

15. List the total number of instructors __________________

______Number of USPTA certified ______ Number of PTR certified _____Number of Minority

16. Please complete the following budget information:

List total amount of organizational budget $_____________________________

List amount of NJTL budget (if different from organizational budget) $_____________________________

List amount raised from in-kind donations $_____________________________

List amount raised from private sector fundraising $_____________________________

List amount provided by public sector $_____________________________

List amount raised by program fees charged $_____________________________

17. Which of listed service organizations were involved?

q Church/Religious Group q Parks & Recreation q USPTR

q USPTA q Community Tennis Assoc. q Public Schools District

q Boys/Girls Clubs q YMCA/YWCA q Other:_________________

Regional Rally

18. Did your chapter/program attend a Regional Rally? q YES q NO

If yes, please name Regional Rally Host Site ______________________________

19. How many participants from your chapter/program attended? _________________________

20. Would you be interested in hosting a Regional Rally? q YES q NO

Program Aids

21. Which of listed program aids do you find to be most helpful:

q On Court Guide q Posters q USA Tennis NJTL Brochure

q Arthur Ashe Video

22. Which of listed program aids do you find to be less helpful:

q On Court Guide q Posters q USA Tennis NJTL Brochure

q Arthur Ashe Video

Promotional Items

23. Did your chapter/program purchase any USA Tennis NJTL promotional items since your last report?

q YES q NO If yes, were you satisfied with the items?

q YES q NO

If no, please state reason for dissatisfaction:______

Service

24. How can your USTA Section Office serve you better?

____________________________________________________________________

____________________________________________________________________

25. When would be a good time for a USTA representative to visit your on-court activities?

List dates & times:_______________________________________________

Additional Comments:_______________________________________________

____________________________________________________________________

____________________________________________________________________

Name of person completing this form:

____________________________________________________________________

Name (please print) Date

 

 
 
 
 
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