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GSGA Adaptive Golf Program
Community Clinic Sign-Up Form
PARTICIPANTS
Crosswinds Golf Club - Savannah
232 James B. Blackburn Drive, Savannah, GA 31408
(complete this form and select date below)
First Name:
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Participant's First Name
Last Name:
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Participant's Last Name
Preferred Email:
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Phone Number:
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GSGA Adaptive - Savannah - 2024 Clinic Dates
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Select Clinic Date(s) - REMEMBER TO MARK YOUR CALENDARS!
Thursday, May 9 (makeup date is May 23)
Thursday, June 13
Thursday, July 11
Thursday, August 8
Thursday, September 12
Thursday, October 10
Thursday, November 14
Thursday, December 12
How many guests are coming with you?
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Participant Information/Release
Street Address:
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City:
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State:
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Postal Code:
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Date of Birth:
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Month
/
Day
/
Year
Please indicate your impairment category
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Spinal Injury/Wheelchair/Assisted Device
Neurological/TBI/Stroke/Impaired Balance
Limb Absence/Limited Use
Sensory/Vision/Hearing Impairment
Cognitive/Intellectual Impairment
Short Stature
PTSD
Recent Surgery/Joint Replacement
Other (please describe below)
Are you a wheelchair user?
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Yes
No
Any other information you would like to share?
Medical Conditions/Allergies:
Medications/Dosages:
Physician's Name & Phone Number:
In Case of Emergency -
Name:
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Relationship:
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Phone Number:
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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