| Student Information |
| Gender | Male
Female
|
| Date of Birth | |
| Age | |
| Address | |
| City | |
| State | |
| Zip | |
| Parent/Guardian Name | |
| Home Phone | |
| Work Phone | |
| Cell Phone | |
| Grade Level | |
| Email Address | |
| Would you like to be notified by email of upcoming events? | Yes
No
|
| School Name | |
Attended any previous first tee classes or camps?
(select all that apply) | |
Skill Level
(select all that apply) | |
| Health Information |
| Physician’s Name | |
| Phone | |
| Other Emergency Contact | |
| Phone Number | |
Please check all that apply.
(select all that apply) | |
| Other medical | |
| Any other comments | |
| Health Insurance Carrier | |
| Policy Number | |
| Insured Name | |
| OPTIONAL: Please check for statistical purposes only. |
Does your family currently qualify for the federal school lunch program?
(select all that apply) | |
Has your child participated in our program through their physical education class?
(select all that apply) | |
Ethnicity
(select all that apply) | |
Family Income
(select all that apply) | |
|
| Parent/Guardian Signature | |
I/We the parents/legal guardians of the above named youth give approval of participation in The Children’s Course Program’s* sponsored activities. I/We assume all risks of injury whatsoever and agree to hold harmless The Children’s Course from claim(s) of any nature arising from any activity, including transportation, connected with The Children’s Course Programs. This hold harmless agreement includes, but is not limited to, any claim for injury proximately resulting from negligence of The Children’s Course, its employees, agents, LPGA and PGA Professionals, participating agencies, and volunteers.
I/We understand that any golf equipment received for use is property of The Children’s Course, and must be returned upon termination of program involvement.
The undersigned hereby gives The Children’s Course and participating agencies permission to use any film, videotape, and photographs of the above mentioned minor for any lawful promotional or informational purpose.
In the event that I cannot be reached in an emergency, I agree to accept any and all determinations of need for medical assistance and/or administration of medical attention as deemed necessary by The Children’s Course representatives. I hereby give permission to the medical personnel selected by The Children’s Course representatives to secure any and all advised hospitalization, medical, dental and/or surgical treatment.
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| Date | |
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