Clinic Registration

Personal Information

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth

Liability Waiver *

Please read the following carefully before signing.

RELEASE OF LIABILITY, WAIVER OF CLAIMS & INDEMNIFICATION AGREEMENT

In consideration of being permitted to participate in any and all activities organized by North Carolina Adaptive Golf ("NCAG"), I, the undersigned, hereby acknowledge and agree to the following:

1. Assumption of Risk: I understand that participation in adaptive golf activities involves inherent risks, including but not limited to physical injury, falls, equipment-related incidents, and other unforeseen hazards. I voluntarily assume all such risks.

2. Release of Liability: I hereby release, waive, discharge, and covenant not to sue NCAG, its founders, volunteers, coaches, partners, and affiliates from any and all claims, damages, or causes of action arising out of my participation in NCAG activities, to the fullest extent permitted by law.

3. Medical Authorization: I authorize NCAG staff to seek emergency medical treatment on my behalf if I am unable to do so myself. I certify that I am physically able to participate and have no medical conditions that would prevent safe participation without proper disclosure.

4. Indemnification: I agree to indemnify and hold harmless NCAG and its representatives from any claims, including legal fees, arising from my actions during participation.

This waiver is binding upon my heirs, executors, and legal representatives.

I have read and agree to the Liability Waiver above. *

Media Release *

PHOTO, VIDEO & AUDIO RELEASE

I hereby grant North Carolina Adaptive Golf and its representatives the right to photograph, film, record audio, and otherwise capture my likeness during NCAG events and activities. I authorize NCAG to use, reproduce, publish, and distribute such materials — including on social media, websites, promotional materials, and news outlets — without compensation. I waive any right to inspect or approve the finished content.

I consent to photos, videos, and audio recordings of me being posted online and used in NCAG promotional materials. *

Electronic Signature *

Full Name (Electronic Signature) *

Date

By typing your name above, you acknowledge that this constitutes a legally binding electronic signature.

Emergency Contact

Contact Name *

Contact Phone *

Disability & Adaptive Needs

This information helps us prepare the right equipment and accommodations for you.

Disability / Condition Type

Specific Adaptive Requirements or Accommodations

Golf Experience

Experience Level *

Previous Adaptive Golf Programs (if any)

Additional Information

How did you hear about us?

Anything else we should know?