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GSGA Adaptive Golf Program
Military Veterans Adaptive Golf Clinic Sign-Up Form
PARTICIPANTS
Eagle's Landing Country Club
100 Eagle's Landing Way, Stockbridge, GA 30281
(complete this form and select date below)
First Name:
*
Participant's First Name
Last Name:
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Participant's Last Name
Preferred Email:
*
Phone Number:
*
GSGA Adaptive - MVAG - South Atlanta - 2025 Clinic Dates
Saturday, April 19 - 12:00-2:00 p.m.
Saturday, April 26 - 12:00-2:00 p.m.
Saturday, May 3 - 12:00-2:00 p.m.
Saturday, May 10 - 12:00-2:00 p.m.
Saturday, May 17 - 12:00-2:00 p.m.
Participant Information/Release
Street Address:
*
City:
*
State:
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Postal Code:
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Branch of Service or First Responder Affiliation?
Date of Birth:
*
Month
/
Day
/
Year
Please indicate your impairment category
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PTSD
Recent Surgery/Joint Replacement
Spinal Injury/Wheelchair/Assisted Device
Neurological/TBI/Stroke/Impaired Balance
Limb Absence/Limited Use
Sensory/Vision/Hearing Impairment
Other (please describe below)
Any other information you would like to share?
Medical Conditions/Allergies:
Medications/Dosages:
Physician's Name & Phone Number:
In Case of Emergency -
Name:
*
Relationship:
*
Phone Number:
*
Please select your level of golf experience:
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Beginner
Intermediate
Advanced
Additional comments/other info in which we should know about you:
Consent and Release Form & Participant Agreement:
Due to the nature of this golf event, I acknowledge all the foregoing risks on my behalf and accept personal responsibility for any illness, injury or damage that may occur with my attendance. I release, waive, and hold harmless the Georgia State Golf Association, Inc., GSGA Foundation, Inc., host golf facility, sponsoring organizations and any instructors, directors, staff, other participants and/or supporters involved with a GSGA Adaptive Golf event. I grant permission to photograph/film video for purpose of marketing, promoting future adaptive golf programs. I am 18 years or older, agree to the above release and sign it voluntarily for myself and on behalf of "Participant" listed herein on this registration form.
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Submit