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Student Contact Information

First Name *

Last Name *

Address

Address 2

City *

State

Zip

Email *

Phone

Date of Birth *

Level of Experience

Parent Contact Information

Parent Name

Parent Phone Number

Emergency Contact *

Emergency Phone *

Other Pickup

Medical Waiver

Please list specific allergies/treatment *

Please list any special dietary restrictions *

Please list any special medical or psychological information not already mentioned *

If there are medications that your child takes that may have an impact on successful completion of the program, please list here

Are there any other special problems that Copper Hill should know about?

The health information on this sheet to my knowledge is accurate, and the person herein described has permission to engage in all golf program activities except as noted. In the event that I or my designated appointee cannot be reached in an emergency, I give permission to the Physician selected by Copper Hill Golf Academy's Director to secure and administer treatment, including hospitalization, for my child named above.

I agree to the above statement *

Yes No

Notes to Copper Hill

Student Contact Information

First Name *

Last Name *

Address

Address 2

City *

State

Zip

Email *

Phone

Date of Birth *

Level of Experience

Parent Contact Information

Parent Name

Parent Phone Number

Emergency Contact *

Emergency Phone *

Other Pickup

Medical Waiver

Please list specific allergies/treatment *

Please list any special dietary restrictions *

Please list any special medical or psychological information not already mentioned *

If there are medications that your child takes that may have an impact on successful completion of the program, please list here

Are there any other special problems that Copper Hill should know about?

I agree to the above statement *

Yes No

Notes to Copper Hill

Individual

Student Contact Information

First Name *

Last Name *

Address

Address 2

City *

State

Zip

Country

Email *

Phone

Date of Birth *

Level of Experience

Parent Contact Information

Parent Name

Parent Phone Number

Emergency Contact *

Emergency Phone *

Other Pickup

Medical Waiver

Please list specific allergies/treatment *

Please list any special dietary restrictions *

Please list any special medical or psychological information not already mentioned *

If there are medications that your child takes that may have an impact on successful completion of the program, please list here

Are there any other special problems that Copper Hill should know about?

I agree to the above statement *

Yes No

Notes to Copper Hill

Register for Entry Level

Junior Golf Camp - Sport Level 3 Day Ages 6-10 Jun 19, 2024 09:00 am - Jun 21, 2024 12:30 pm

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