Waiver Form

SBJRGolf Waiver Form

Youth Information

Youth's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Youth's Birthdate(Required)

Youth's Age(Required)

Youth's School(Required)

Grade Level(Required)

Statistics Gathering

The Stoneybrook Golf Club and Stoneybrook Junior Golf INC. does not discriminate on the basis of gender or ethnicity. This information is requested for statistical purposes only and may be withheld without effect on the eligibility of the youth golfer to participate in the SBJR INC Program.

Gender(Required)

Female

Male

Ethnicity(Required)

African-American

Asian-American

Caucasian

Hispanic

Native-American

Pacific Islander

Other

Prefer not to Answer

Parent's Contact Information

Parent's Email(Required)

Home Phone(Required)

Parent Cell Phone(Required)

Emergency Contact

Emergency Contact(Required)

First Last

Emergency Contact's Phone(Required)

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 Stoneybrook and Stoneybrook Junior Golf INC employees, agents, LPGA or PGA Professionals, participating agencies, and volunteers. I hereby give permission to the medical personnel selected by Stoneybrook employees, agents, LPGA or PGA Professionals, participating agencies, and volunteers to secure any and all medical, hospitalization, dental, and/or surgical treatment. In event that such medical attention is needed from a healthcare provider, I agree that all costs shall be the responsibility of the parent or guardian.

Emergency Procedure: Parent/Guardian Initials*(Required)

I understand that completing this box constitutes a legal signature confirming that I acknowledge and agree to the above.

Emergency Procedure: Participant Initials*(Required)

I understand that completing this box constitutes a legal signature confirming that I acknowledge and agree to the above.

Health and Accommodation Information

Organization to provide Golf Clubs(Required)

Yes - Right-Handed

Yes - Left-Handed

Notes

Are there any medical conditions (allergies, medications, etc.) that the Stoneybrook Junior Golf Program needs to be aware of?(Required)

Yes

Medical Conditions(Required)

Does your child require reasonable accommodations in order to participate in the program?(Required)

Yes

Accommodations(Required)

Media Release

I hereby give Stoneybrook Golf Club and SBJR INC and its employees, agents, LPGA or PGA professionals, participating agencies, volunteers, and community permission to use film, video tape and/or photographs of the above-mentioned minor/participant for lawful promotion or informational purposes.

Parent/Guardian Initials

Participant Initials

Code of Conduct

Code of Conduct The participant and parents of other representatives of participant understand and agree to abide by the rules and regulations set forth in the Code of Conduct and acknowledge receipt of a copy of the Code of Conduct. This includes during events, as well as in written correspondence and electronic social media interactions. If we fail to do so, there are consequences which may include suspension or cancellation of benefits and/or being prohibited from participating in future events hosted by Stoneybrook Golf Club. Stoneybrook Golf Club has absolute discretion in enforcing this policy. The safety of staff and participants is the Club’s number one concern.

Code of Conduct: Parent/Guardian Initials*(Required)

I understand that completing this box constitutes a legal signature confirming that I acknowledge and agree to the above.

Code of Conduct: Participant Initials*(Required)

I understand that completing this box constitutes a legal signature confirming that I acknowledge and agree to the above.

Waiver

I, the parent/legal guardian of the above named youth, give approval for the youth’s participation in Stoneybrook Junior Golf activities. I understand that Stoneybrook Junior Golf Program is an independent organization which benefits from the participation of many golf organizations including The First Tee and its oversight organizations PGA TOUR, PGA of America, USGA, Augusta National Golf Club, the LPGA and Stoneybrook golf club and community. The golf course is owned by the Stoneybrook Community Development District. I assume all risks of injury whatsoever and agree to hold harmless the Stoneybrook Community Development District, its employees, officers and contractees, and the Stoneybrook Junior Golf Program, including its oversight organizations, from claim(s) of any nature arising from any activity, including transportation, connected with Stoneybrook facility or program(s). This hold harmless agreement includes, but is not limited to, any claim due to injury proximately resulting from negligence of the Stoneybrook Community Development District or the Stoneybrook Junior Golf Program, Stoneybrook Golf Club or its oversight organizations, employees, agents, LPGA or PGA Professionals, participating agencies, and volunteers. I consent to The Stoneybrook Golf Club and its community communicating information regarding my child’s participation in this program via the internet.

Waiver: Parent/Guardian Initials*(Required)

I understand that completing this box constitutes a legal signature confirming that I acknowledge and agree to the above Waiver.

Waiver: Participant Initials*(Required)

I understand that completing this box constitutes a legal signature confirming that I acknowledge and agree to the above Waiver.

Waiver: Witness Signature*(Required)

I understand that completing this box constitutes a legal signature confirming that I acknowledge and agree to the above Waiver.