2017 Spring Program Registration Form

PO Box 1820 Shallotte, NC 28459 (910) 754-5288 www.thefirstteebc.org Tax ID #27-0106935

2017 Spring Program Registration Form Please print clearly and mail in the completed form with your payment to the address above. Your child’s spot is not guaranteed in our program until payment is received! Participant First Name: ______Last Name: ______DOB: __/__/___ Age as of 3/14/17: ____ Participant Gender: ___ - Male ___- Female School: ______Grade Level: ______Participant Ethnicity (Select One): ___- Asian ___- Black or African American ___ - Latino or Hispanic ___ - Multi-Racial ___ - Native American or Pacific Islander ___ - White or Caucasian Please select class desired below: (For Scholarship Assistance Questions Please call 910-754-5288). $40 Program Fee for PLAYer, PAR, BIRDIE, EAGLE & ACE - $25 for Little Linksters & Girls Golf. ______PLAYer Tuesday (4:30-6:00 PM) @ The Golf Park at Cinghiale Creek (Shallotte area) ______PLAYer Thursday (4:30-6:00 PM) @ Olde Fort (Leland area ______PLAYer Thursday (4:30-6:00 PM) @ South Harbour Par 3 (Southport/Oak Island Area) ______PLAYer Saturday (8:30-10:00 AM) @ The Golf Park at Cinghiale Creek (Shallotte area) ______PLAYer Wednesday (4:00-5:30 PM) @ Carolina National (Bolivia area) ______PAR Wednesday (4:30-6:00 PM) @ Magnolia Greens (Leland area) ______PAR Wednesday (4:00-5:30 PM) @ Carolina National (Bolivia area) ______PAR Saturday (8:30-10:00 AM) @ The Golf Park at Cinghiale Creek (Shallotte area) ______PAR Tuesday (4:30-6:00 PM) @ The Golf Park at Cinghiale Creek (Shallotte area) ______PAR Thursday (4:30-6:00 PM) Oak Island (Southport/Oak Island area) ______BIRDIE Tuesday (4:30-6:00 PM) @ The Reserve Club at St. James (Southport area) ______BIRDIE Wednesday (4:30-6:00 PM) @ Magnolia Greens (Leland area) ______BIRDIE Thursday (4:30-6:00 PM) @ The Golf Park at Cinghiale Creek (Shallotte area) ______BIRDIE Saturday (11:30-1:00 PM) @ The Golf Park at Cinghiale Creek (Shallotte area) ______EAGLE Saturday (10:00-11:45 AM) @ The Golf Park at Cinghiale Creek (Shallotte area) ______EAGLE Thursday (4:30-6:00 PM) @ St. James Members Club (Southport area) ______ACE Saturday (2:00-4:00 PM Dates TBA) @ St. James Plantation (Southport area) ______LITTLE LINKSTERS - Every other Friday (4:45-5:30 PM) @ The Golf Park at Cinghiale Creek (Shallotte area) ______GIRLS GOLF - Every other Friday (4:30-6:00 PM) @ The Golf Park at Cinghiale Creek (Shallotte area) Please list health limitations (if any) for your child: ______Emergency Contact Name: ______Emergency Phone #: ______Parent/Guardian Info: First Name: ______Last Name: ______Relationship to Participant: ______Address: ______City: ______State: ______Zip: ______Email: ______Cell: ______Employer: ______Parent/Guardian Work #: ______2017 Spring Program Registration Form Medical Release -(Parent/Guardian initials required below) In the event that I cannot be reached in an emergency, I agree to accept any and all determinations of need for medical assistance and/or administration of medical attention deemed necessary by The First Tee chapter representatives. I hereby give permission to the medical personnel selected by The First Tee Chapter Representatives to secure any and all medical, hospitalization, dental and/or surgical treatment. In the event that such medical attention is needed from a healthcare provider, all costs shall be the responsibility of the parent or guardian. ______(Parent/Guardian Initials).

Participation Risk Acknowledgement - (Parent/Guardian initials required below to participate in The First Tee Programs & Activities). I, the parent / legal guardian of the above named youth, give approval for participation in The First Tee spon- sored activities. I assume all risks of injury whatsoever and agree to hold harmless The First Tee Chapter and Headquarters Office from claim(s) arising from any activity, including transportation, connected with The First Tee facility or program. This hold harmless agreement includes, but is not limited to, any claim due to proximate injury resulting from negligence of The First Tee Chapter or Headquarters Office, its employees, agents, LPGA and PGA professionals, participating agencies, and volunteers. I consent to The First Tee Chapter and Headquarters Office communicating information regarding my child's participation via the internet. ______(Parent/Guardian Initials).

Media & PR Release - (Optional Parent/Guardia initials below) I hereby give The First Tee Chapter, Headquarters Office, and participating agencies permission to use film, video tape, and/or photographs of the above mentioned minor for lawful promotional or informational purposes. ______(Parent/Guardian Initials).

If your child needs golf clubs please complete a Rental Request Below - ($10 per calendar year rental fee!): *** Please Note: Little Linksters do not need to rent golf clubs! *** When answering the "Type of Rental Request" question on this form: Select "New" if your child does not have a set of rental golf clubs and we need to build them a set. $10 per calendar year rental fee! Select "Renewal" if your child already has a set of our rental clubs and just needs to pay the rental fee again for 2017. $10 per calendar year rental fee! Select "Trade-In" if your child has a set of rental clubs that they have out grown and they need a new set of rental clubs. Please return / "Trade-In" the old set of rental clubs when you pick up the new set of rental clubs. IMPORTANT: Please be sure to update their height in inches on the form! $10 per calendar year rental fee! Type of Rental Request? ____ - New ___ - Renewal ___ - Trade-In Is your child Right or Left Handed? ___ - Right Handed ___ - Left Handed IMPORTANT - What is your child’s current height in inches? My child is _____ - inches tall Equipment Acknowledgment - - (Acknowledgement required below to rent golf clubs and participate in The First Tee Programs & Activities) There is a $10.00 fee for your rental clubs each calendar year. Your child's rental golf clubs will be available from your coach on the first day of class if you order them at least 10 days in advance. I understand that any golf equipment issued to my child for use in The First Tee Chapter program is the property of The First Tee of Brunswick County and must be returned upon request or upon termination of my child's involvement in the program. ______(Parent Initials).

Marketing Info: How did you learn about our 2017 Spring Program Registration? Please check all that apply: ___- Email Blast ___ - Brunswick Beacon ___ - State Port Pilot ___ - Flyer at Golf Course ___ - The First Tee Web Site ___ - Facebook Post ___ - Youth Participant ___ - Adult Volunteer ___ - Friend ___ - Other (Please Specify) ______Payment Info: Payment Type (Credit/Debit Online Only – Select One): ___ - Cash ___ - Check (#______) Name of person accepting form & payment? ______Total Payment Amount $______