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GSGA Adaptive Golf Program
Community Clinic Sign-Up Form
PARTICIPANTS
RiverPines Golf, Johns Creek - North Atlanta
4775 Old Alabama Road, Johns Creek, GA 30022
(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:
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Phone Number:
*
GSGA Adaptive - North Atlanta - 2024 Clinic Dates
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Select Clinic Date(s) - REMEMBER TO MARK YOUR CALENDARS!
Tuesday, May 28
Tuesday, June 25
Tuesday, July 23
Tuesday, August 27
Tuesday, September 24
Tuesday, October 22
Tuesday, November 26
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?
*
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