t_
bE
*g
^F
si"
:q fl
fi
f i"
+ e i'r r [: E A s s R
iE
E5?#{E+;
E E {"
=;?#t
L
9,
=
*
E.=iEiE eV EEsd; Nf $; {*3
q t * H:EEi
'r! EiHIH€$"a
N; c - -6 i€
" F
!=
,-'
sF
)*
s
.E Ei
'o
t
$E
fi
H
Ed
o
bl
fI
g
E
o
IJ
ul-
s6
ulF
ao
o,
EH
!-
a-
z
tra-
.u
cr2
-l-
(b
IsF.=
**3
o-
^tr;
?-(U g
.s5
tJ
ffiffi
= r.- X .t
k
&
5s E t$
F:
E
€er
$
r* F€tE
#a
eEeE Irefr :r5E.cgE^j
i
i
oo9
F'
lE ;g fl fl ;i E, * E t
Ei EEi
Efi E
2' H5lf.B-F
E f iF ig Is E : 5 * $r
'E
f; 5f sEiiq'g;
B
;5
6 E L -tr
g g i 5 !5 !;;l$=;9F;
i tiEE
+ ; I Ei
;
t'
{(E
o
=
s?a
3Et
lOrn
6tE
tL= o
$$E ggE
398
*Iii*Ei-EE:FgE
B e r*
.LC,
J (9OJ
o
6
iiFF,iilfFfii'iig
EEgifi3i$Er#f
tr
o
IL
UJ
J
o
J
>a
<J
trr lfl
E>
<5
Or
z'i
o?
@
a
ut
o
o
z
o
IPGA-USGA Girls Golf of Greater Newark
2OL2 REGISTRATION for GROUP LESSONS
The Learning Center Galloping Hill Golf Course
Kenilworth, New fersey
Wednesdays, May 23, 2OL2 - AUGUST 1,2012
5:30 P.M. -7:00 P'M.
fno class fulY 4th)
LPGA and PGA certified golf
instruction /LPGA-USGA Girls Golf Membership Fee for 2012 calendar year/
LPGA-USGA Girls Golf Membership
kit
Last Name
First Name
Street
State
City
Tel-
Zio
Parent Emai
Home #
Cell Phone #
Mother/Guardia
Work#
Home#
Father/Guardia
We should be aware of)
Work#
Home#
Emergency Contact
Parent/Guardian Information
WAIVER AND RELEASE: Acknowledging that participation in athletics carries risk of physical injury, I agree that Renaissance Junior Golf, lnc.,
Galloping Hill Golf Course, KemperSports and County of Union, its agents, commissioners and employees, shall not be liable to me for any
injury or damage, howsoever caused, resulting directly or indirectly from my participation in the Galloping Hills programs, at any time
preceding, during or after the program is in session and I hereby discharge Galloping Hills Golf Course, its agents, commissioners and
employees from all actions, claims, and demands I may have for such injury or damage. I authorize that Galloping Hill Golf Course has the
right to use all photographs or videos taken of me during the academy for advertising or promotional material.
Date
Official Use OnlY
Date
Does
Paid-
Check /Money Order #
your child have any medical conditions or allergies?
If you have any questions or need additional information email: [email protected] or call 2OL-662-0733
for $110.00 payable to LPGA-USGA Girls Golf of Greater Newark
Complete 2012 Registration Form and LPGA-USGA Participation Form and mail to:
Check or money order
Beverly E. Harrison, jD
c/o LPGA-USGA Girls Golf
8200 Boulevard East #21a
North Bergen, New |ersey 07047
F
-sA
SK
.F**Xl;;:,
ffi,AII
#Po
rticilant F6rm
Potticlpant Informatlon - pleose print ot type - oll information is reguired
LPGA-USGA Girls Golf of (city, state) GREATER NEWARK, NEW JERSEY
Address
Participant's Name
Participant's Birch
/
Date /
Dav Phone
Parent/Guardian
School
-
(
)
Parent Email
Grade
Consent & Releose
HomePhone(_)
zip
State
City
Parcnt or Guardian MUST sign in space indicated below for application to be considercd.
Parcnt /Guardian Statement
l, the parent (or guardian) of the participant named above, am familiar with the plans and purposes of LPGA-USGA Girls Golf and give full permission for my
child/ward to atrend LPGA-USGA Girls Golf enents and to participate in all phases of LPGA-USGA Girls Golf activities. I understand that, by signing this Consent
& Release Form below I agree to waive and release any rights and claims for damages against, and hold harmless LPGA-USGA Girls Goll LPGA,The LPGA
Foundation, the USGA, and each of their respective officers, directors, employees, volunteers, workers, members and agents, from and against any and all injuries
or damages which may result from or arise out of rny child's/ward's participation in LPGA-USGA Girls Golf events and activities.
Dispute Resolution
ln the glrent of a controversy or claim arising out of or relating to this Panicipant Form the undersigned hereby agrees to arbitration held in a mutualb/ agreeable
location in accordance with the Commercial Artitration rules of theAmerican Arbitration Association. A judgment rendered by the arbitrators shall be final and
nonappealable, and may be entered in any couft having iurisdiction thereof.
Medical Emergency Statement
the parent (or guardian) of the panicipant, give my permission for my child/ward to receive emergency medical treatmenq if necessary as a result of participation
in the LPGA-USGA Girls Golf program. lt is understood that wery effort will be made to contact me before taking this action.
l,
Release of Par{icipant
Person(s) other than parent who may pick up the participam at the end of any LPGA-USGA Girls Golf evenc
St.tte
Rerotlonshi?
ln Witness Whercof
DoyPhone
Nrght Phone
I have read, understand and agree
* PARENT/GUARDIAN
ZIP
to this entire consent form.
SIGNATURE REQU IRED
Golfing b<perlence
Please check the level that best describes your ability:
fl a""" t:
I f"""t ll:
[-l levet lll:
o<perience. I
Able to play hole 125 yards fiom green
n
Average bewveen 65-75 for nine holes on a r.eguladon course.
I
New Golfer -\6qr litrle or no on-course
Do you own your own
clubs?-
levet lV:
Level
V:
Arrerage betsreen 55-64 firr nine holes on a regulation course.
Play 18 holes with a score
of I l0 or better on a regulation course.
f""", Yl: Play 18 holes with a score of95 or better on a regulation
course.
Other junior golf affiliation
Photo & Press Releose
hereby consent that any photographs and/or motion pictures
of
or videotape in which ny child/ward appears, and any audio recordings made of her voice may be used by LPGA-USGA Girls Golf, its assigns or successors, in
l, being ParendGuardian
whatever way they desire, including television and electronic media; furthermore, I hereby consent that such photographs, films, and recordings, and the plates and/
or tapes, from which they are made shall be their property, and they shall have the right to sell, duplicate, reproduce, and make other uses of such photographs,
films,recordings,plates,andtaPesastheydesirefreeandclearofanyclaimwhatsoeveronmyPart.-('Nl7,Al.soFPARENT,/GUARD,Ar9
For statistical purposes only (optional - you:Me not required
I
Ataskan Native / American
lndian
I
ati"n /
Pacific
b
answer) Which of the following best describes your race or ethnic group?
lslander
f,l
Bfact or African American
I
Hispanic
I
Wnite
ft
Otnet
1.20.2012
r
dilsul
PARTICIPANT AGREEMENT
LfrA*U*A
1.
2.
3.
I will respect the environment and the people with whom I come in contact and will try to be sensitive
to the needs of each participant in LPGA-USGA Girls Golf.
I understand that the use of alcohol or illegal drugs will not be tolerated and that usage during any
LPGA-USGA Girls Golf event will result in expulsion from both the program and the event.
I will be responsible for my personal belongings and equipment and will not hold LPGA-USGA
Girls Golf, LPGA, The LPGA Foundation, the USGA or their employees responsible for their loss due
to my negligence or abuse.
4.
5.
6.
7.
I will treat the facilities and equipment provided by LPGA-USGA Girls Golf with care. I understand
that I will be assessed for any damage to facilities or equipment caused by my negligence or abuse.
I will use any safety equipment furnished by LPGA-USGA Girls Golf for my own safety.
I understand that if I am sent home early due to any serious misconduct, it will be at my expense, and
LPGA-USGA Girls Golf will make my travel arrangements.
I will comply with the LPGA-USGA Girls Golf Code of Ethics.
Participant's Signature
Participant's Name (Please print)
Participant's Parent/Guardian Name (Please
print)
Date
Participant's Parent/Guardian Signature
Date
THIS AGREEMENT MUST BE SIGNED BY THE PARTICIPANTAND PARTICIPANT'S PARENT/GUARDIAN
fiI
dils
lfrA*U*A
LPGA.USGA GIRLS GOLF CODE OF ETHICS
Treat others as you would like to be treated
Replace divots
Rake bunkers and repair ball marks so you leave the course better than you found
it
Club throwing, swearing, cheating,littering or smoking are not acceptable
Always thank the host professional
GG6.3.11