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No Limit Clinic
Five Ponds Golf Course
1225 W. Street Rd. | Warminister, PA 18974
October 12, 2024 2:00-3:30 p.m.
First Name
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Last Name
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Email
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Phone number
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Street address
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City
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State/Region
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Date of Birth
Month
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Day
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Year
Gender
Ethnicity
Asian/Asian American
Black/African American
Hispanic/Latino/Chicano
Middle Eastern or North African
Native American/Alaska Native
Pacific Islander
White/Caucasian
Other
Prefer Not To Say
Disability / Impairment
Above Knee Amputee
Below Knee Amputee
Double Leg Amputee
Arm Amputee
Multi-Limb Amputee
Impaired Muscle Power
Impaired Passive Range of Movement
Limb Deficiency
Leg Length Difference
Short Stature
Ataxia
Athetosis
Vision Impairment
Intellectual Impairment
Other
Neurological/TBI/Stroke/Impaired Balance
Limb Absence/Limited Use
PTSD
Sensory: Vision/Hearing Impairment
Spinal Injury/Wheelchair/Assisted Device
Recent Surgery/Joint Replacement
Are you a Veteran?
Yes
No
To your knowledge, do you need/use any adaptive equipment?
Emergency Contact
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Will you be bringing any guest with you?
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Yes
No
If yes above, please list their name and relationship to you.
Level of Golf Experience
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Beginner
Intermediate
Advanced
Additional Comments/Other Information We Should Know About You
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