Toledo Pickleball Glass City Invitational

Friday, Saturday & Sunday, July 17-19, 2015

Women’s Doubles* & Men’s Singles* (Friday) | Mixed Doubles* (Saturday)

Men’s Doubles* & Women’s Singles* (Sunday)

Double Elimination; USAPA Rules; Doubles Skill Levels: 3.0, 3.5, 4.0, 4.5, 5.0; Singles (Open)

LOCATION: Toledo Pickleball Courts, Just north of the US Post Office at 313 Glenwood Rd, Rossford, OH

REGISTRATION FEE: $30.00 ($10 for each doubles events, $5 for singles)—nonrefundable,

includes dri-fit shirt, water, snacks

Registration deadline: Must be postmarked by July 6, 2015.

Tournament Schedule: Registration Begins at 8:00 am, Play Begins at 9:00 am

* Event draws will be limited. In the event of inclement weather, matches may be held indoors.

Tournament Director: Connie Mierzejewski, 419-509-3023, bucksrgr8r@aol.com

Make checks payable to: Toledo Pickleball Club, ($30 registration fee, $10 for each doubles events, $5 for singles.)

Clip this entry form above at the line above and mail it no later than July 6th to:

Toledo Pickleball Glass City Invitational, c/o Connie Mierzejewski, 228 Hillsdale Ave., Rossford, OH 43460

ENTRY FORM - PLEASE PRINT

Name: ______________________________________________________________________________ Shirt Size: S M L XL XXL

Address: ____________________________________________________________________________________________________

City/State/Zip: _______________________________________ Phone: ____________________________________________

Email: ____________________________________________________________________________________ Gender: M __ F __

Singles: ___ Skill Level: ____ | Doubles: ____ Skill Level: ____ | Mixed Doubles: ____ Skill Level: ____

* (Please indicate your gender, the event(s) you are playing in and your skill level in the spaces above.)

Doubles Partner’s Name: ___________________________________________ Doubles Skill Level: _____

Mixed Doubles Partner’s Name: ___________________________________________ Mixed Doubles Skill Level: _____

PLEASE SIGN, DATE & RETURN THE WAIVER RELEASE FORM ON THE BACK OF THIS FORM

LIABILITY WAIVER

I, __________________________________________________________________________________________________________

Name (Please Print)

Home address:

________________________________________________________________________________________________________________________

Street City State Zip

acknowledge that I am aware that certain risks are or may be associated with activities sponsored by the Toledo Pickleball Club, and I personally

assume all such risks for the participation of myself in any activities in which I take part. I assume full responsibility to become educated regarding

the proper and safe use of any equipment associated with the activities in which I am involved, and the responsibility to abide by all safety rules

promulgated by the Toledo Pickleball Club in relation to said activities. I likewise assume full responsibility to obtain medical clearance from my

physician to participate in the activities offered by the Toledo Pickleball Club. In consideration of the permission granted to me by the Toledo

Pickleball Club to participate in the activities it sponsors, I hereby release the Toledo Pickleball Club and their agents, consultants or employees

from all actions, causes of action, damages, claims or demands which I or my heirs, executors or assigns may have against these entities/persons

for all injuries or property loss or damage which I may incur by participating in said activities.

I have read this informed consent/release of claims and understand its terms. I execute it voluntarily and with full knowledge of its significance.

In witness whereof, I have executed this release this ___________ day of _________________________________ in the year 2015.

__________________________________________________________________

Adult Guest Signature

Medicare Coverage & Costs When Staying in the Hospital Overnight

If you stay overnight in the hospital, your costs and coverage will depend on whether you have inpatient status or outpatient status in the hospital. Staying overnight in the hospital does not make you a hospital inpatient. You only become an inpatient after your doctor formally admits you to the hospital. In general, doctors will only admit you if they expect you will need to stay at least 2 days overnight in the hospital. Part A covers most of your care when you have inpatient status. However, when you are in the emergency room or in the hospital under observation, you are usually an outpatient. You may be under observation if your doctor is keeping an eye on you to decide whether or not to admit you. Observation services may look and feel exactly like inpatient services. Observation can last just a few hours or longer. Part B covers your care, including observation services, when you have outpatient status. Whether your care gets covered under Part A or Part B makes a difference. You will likely pay more for care if it’s considered outpatient rather than inpatient. It also effects whether you may qualify for Medicare to pay for your stay in a skilled nursing facility (SNF) after you leave the hospital. See below for more information. Your patient status can change during your stay. Ask if you are an inpatient or outpatient repeatedly.  If you are unable to ask this yourself, your family members and caregivers can ask for you. Read below to learn about your costs for hospital care as an inpatient or outpatient. The costs discussed below apply to those with Original Medicare.  If you have a Medicare Advantage plan, your costs in the hospital may be different. Contact your plan for information about what you pay for an inpatient or outpatient hospital stay. Costs for inpatient hospital care When you are admitted to a hospital as an inpatient, you pay a one-time deductible for most hospital care provided, and then have no copayments for the first 60 days. Medicare Part A covers nurse’s services, medically necessary medications, X-rays, supplies, appliances, and equipment the hospital provides for you to use during your inpatient hospital stay. Medicare Part B covers doctors’ services you receive in the hospital.  You usually owe a separate 20 percent coinsurance for these doctors’ services.  Your status as a hospital inpatient may qualify you for Medicare to pay for a SNF stay if you need it after you leave the hospital. In order to qualify for a Medicare-covered SNF stay, you must have been a hospital inpatient for at least 3 days and meet other requirements. The day you become an inpatient counts toward the qualifying days; the day the hospital discharges you does not count toward the qualifying days.  Costs and coverage for outpatient hospital care If you are an outpatient during your hospital stay, Medicare Part B covers most of your services. You typically pay a coinsurance for each medical service you receive in the hospital after you meet the Part B deductible. For example, you will have separate charges for emergency room care, observation care, x-rays and lab tests. You must also pay the coinsurance for physician services you receive. Physician services include any time you spent with a physician while you were in the hospital, even if that physician was not your primary doctor or surgeon. Original Medicare Part B generally covers 80 percent of the cost of most services you receive after you have met your yearly deductible. In most cases, you are responsible for paying the remaining 20 percent coinsurance. When Part B covers your hospital care, you may have higher costs than if Part A covers your stay.

You may have multiple coinsurances. Each individual copayment must be less than the Part A deductible ($1,260 in 2015). However, if you add up the coinsurances for each service the total could be higher than the Part A deductible. Part B will not cover the cost of your prescription medications that you routinely take. You will need to get them covered by Part D.  If the hospital pharmacy is not in your Part D plan’s network, you typically have higher out of pocket costs than you would at an in-network pharmacy. You will need to pay the hospital for these medications and then send the bill to your Part D to pay its share of the costs. The days spent as an outpatient do not qualify you for a SNF stay. As a result, you will need to pay the full cost your SNF stay.  Medicare Part B may pay for certain skilled services (like physical therapy) you receive while staying in the SNF.

*This information was provided by the Medicare Rights Center www.medicarerights.org