GSGA Adaptive Golf Program

Community Clinic Sign-Up Form

PARTICIPANTS

Cedar Lake Golf Club - East Atlanta

5720 South Sharon Church Road, Loganville, GA 30052

(complete this form and select date below)

First Name:*

Participant's First Name

Last Name:*

Participant's Last Name

Preferred Email:*

Phone Number:*

How many guests are coming with you?*

Participant Information/Release

Street Address:*

City:*

State:*

Postal Code:*

Date of Birth:*

Month/Day/Year

Please indicate your impairment category*

Are you a wheelchair user?

Yes

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:*

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.*