No Limit Clinic 
Frosty Valley 
July 21, 2024 1:00-2:30 p.m.

First Name*

Last Name*

Email*

Phone number*

Street address*

City*

State/Region*

Date of Birth

Month/Day/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

To your knowledge, do you need/use any adaptive equipment?

Are you a Veteran?

Yes

No

Emergency Contact *

Will you be bringing any guest with you?*

Yes

No

If yes above, please list their name and relationship to you.

Level of Golf Experience*

Beginner

Intermediate

Advanced

Additional Comments/Other Information We Should Know About You

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