Intermediate Program 2024

Student First Name: *

Student Middle Name:

Student Last Name: *

Age: *

Date of Birth - mm/dd/yyyy: *

Gender: * Male Female

Street Address: *

City: *

State: *

Zip Code: *

Email: *

Phone: *

Race: * Asian African American Hispanic White Other

School: *

Medical Condition: *

Additional Instructions:

Parental Authorization: * I hereby give my approval for my child to participate in any and all activities at Button Hole Golf. I assume all risks and hazards incidental to such participation including transportation to and from activities and do hereby waive; release; and agree to hold Button Hole Golf and all individuals blameless for the conduct or activity involving this child..

Media Release: * I grant Button Hole Golf the right to photograph; videotape; and film my child and grant the right in perpetuity to use my child name likeness; biographical information; and voice in all forms of media i(including but not limited to the Button Hole Websites and it's affiliated Social Media Sites) for advertising and promotion of Button Hole Golf and Teaching Center'.