NCGA GHIN#________________20__ YOC sticker rcvd date_____Temp card rcvd date:_______

Name:________________________________________________________

Gender: Female____ Male____Approximate Height: _______________

Address:_______________________________City:_____________ State:____ Zip:___________

Ethnicity: African-American__ Asian-American__ Caucasian__ Hispanic__ Native-American__

Pacific Islander__ Other__

Birth Date (____/_____/_____) Current Grade Level____Email____________________________

Phone: (day) __________________________(evening)_________________________________
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Golfing Information
Has your child ever played 9-holes of golf on a course: Yes       No         If Yes, Avg. Score: ___________
Does your child have there own clubs?    Yes       No
Has your child ever received golf lessons?YesNo
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Payment Method (check all applicable boxes)

___$50.00 one time registration fee                 or               ___ Juniors at Las Positas member
- Receive NCGA Membership
- NCGA Youth on Course certification class (Second Saturday of every month)
- Receive US Kids Golf Hat/Towel

___$119.00 - US Kids Golf Level 1 (Blue Level) Session #: _____      Day:_____________

___$129.00 - US Kids Golf Level 2 (Gold Level)Session #: _____      Day:_____________

___$129.00 - US Kids Golf Level 3 (Red Level)Session #: _____      Day:_____________

FOR SESSION DATES AND TIMES, PLEASE GO TO www.JUNIORSATLASPOSITAS.com

Check enclosed ___ make check payable to Juniors at Las Positas
(If credit card may fax to 925-455-7838) (mail to 917 Clubhouse Drive, Livermore, CA 94550)

Credit Card #_____________________________________________________ Expiration Date: ___________________
Visa/MasterCard/American Express accepted

Name as shown on card:_____________________________________________Amount Paid:______________________
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Emergency / Health Information

Emergency Contact: ___________________Relationship:___________________ (if parent/guardian cannot be reached)
Phone for Emergency Contact:____________________________________________________________
In case of injury to my child, I authorize Las Positas staff to administer minor first aid. 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 Las Positas staff. I hereby give permission to the medical personnel selected by Las Positas 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.
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Conduct
I understand that in daily play, none of the following is permitted: cheating, swearing, club throwing, horseplay, or failure to treat any golf facility properly. I have discussed these rules with my child and agree that my child will adhere to these rules, and the rules of golf and golf etiquette.
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PRINT PARENT/GUARDIAN FULL NAME:__________________________________________________________

SIGNATURE:__________________________________________DATE:_____________Parent: _____ Guardian: _____