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GSGA Adaptive Golf Program
Community Clinic Sign-Up Form
PARTICIPANTS
Oakview Golf Course - Macon
128 Oakview Club Drive, Macon, GA 31216
10:00 a.m. - 12:00 p.m.
(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?
*
GSGA Adaptive - Oakview GC - 2025 Clinic Dates
Select Clinic Date(s) - REMEMBER TO MARK YOUR CALENDARS!
Tuesday, May 13
Tuesday, June 10
Tuesday, July 8
Tuesday, August 12
Tuesday, September 9
Tuesday, October 14
Tuesday, November 11
Tuesday, December 9
Participant Information/Release
Street Address:
*
City:
*
State:
*
Postal Code:
*
Date of Birth:
*
Month
/
Day
/
Year
Please indicate your impairment category
*
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:
*
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.
*
Submit