Scheduled Day(s) To Attend:
2009 Participant Permission Form Today's Date:_____________
Scheduled Day(s) To Attend:
2009 Participant Permission Form
Today's
Date:_____________
Boundary Oak Diablo Creek Delta View Lone Tree __ Participation: New Return
Spring _Summer __________ Camp_# ___ time: A _B Fall
Youth Information:
Name:__________________________________________________________________
Gender:
□
Female
□
Male
(First) (Last)
Address:______________________________________________
City:__________________
State:____
Zip
Code:________
Ethnicity:
□
African-American
□
Asian-American
□
Caucasian
□
Hispanic
□
Native-American
□
Pacific Islander
□ Other
Birth Date: ( / / )
School:_________________________________________
Grade
Level:___________
Health Info allergies, etc.):_______________________________________
Disability Information:______________________
Parent/Legal Guardian:_________________________________________________
Relationship_______________________
(First) (Last)
E-mail Address*:___________________________________
Phone: (day)___________________
(eve)___________________
Family Income: (WE ARE ASKING THIS FOR GRANT PURPOSES)
□
Below $10,000
□
10,000-$24,999
□
$25,000-$49,999
□
$50, 000-$74,999
□
$75,000-$100,000
□
Above $100,000
Participation Consent Form completed by:
□
Mother
□
Father
□
Legal Guardian *Important for communication purposes
Health
Information
Emergency Contact:___________________________________________________
Relationship:_______________________
(If parent/guardian cannot be reached)
Work Place:___________________________________________________________ Phone:____________________________
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 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:
Equipment:
I understand that any golf equipment received for use is the property of The
First Tee program, and may be returned at the discretion of
The First Tee facility upon the termination of the participant's involvement in
the program.
Parent/Guardian Initials:
Media
Release
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:
I, the parent/legal guardian of the above named youth, give approval for participation in The First Tee sponsored activities. I assume all risks of injury whatsoever and agree to hold harmless The First Tee Chapter and Headquarters Office from claim(s) of any nature 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 injury proximately 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 Signature:___________________________________________ Date:____________________________
Please Print Name:___________________________________________________
GHIN # (School Distribution)
PLEASE RETURN ALL COPIES OF THIS FORM TO The First Tee of Contra Costa office. Thank you!