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Select A Junior Program
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LEARN TO COMPETE
JUNIOR PERFORMANCE TEAM
PART A: Participant Information
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Age
Birth Date
Month
Day
Year
Sex
Female
Male
PART B: Family Information
Parent/ Guardian Name
*
First
Last
Address (if different than child)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Primary Contact Phone
*
Email
*
Emergency Contact Name
*
First
Last
Emergency Contact Relationship
*
Emergency Contact Phone
*
PART C: Participant Medical & Special Needs Information
Severe Allergies
Physical/Development Impairment
ADD/ADHD
Behavioural Conditions
Other Special Conditions
PART D: Photography/Media Release & Waiver
Media Release
*
I give my permission for The Royal Ashburn Golf Club to take photographs of my child during this program session for use in future promotional materials
I do not give my permission for The Royal Ashburn Golf Club to take photographs of my child during this program session for use in future promotional materials
Waiver:
*
I agree to release and save harmless The Royal Ashburn Golf Club, and its employee and other agents from any and all claims or other proceedings, regardless of who makes them, in respect of any damage or injury arising be reason participation in the program by myself or the person(s) who are shown as the “participant”.
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