GOLF REGISTRATION FORM

(See instructions on reverse)

THE BERGEN COUNTY DEPARTMENT OF PARKS

Golf Administration Office,Room 401, One Bergen County Plaza, Hackensack, NJ, 07601

(201) 336-7259

Registration is valid for length of golf season only(March – December)

NAME ______

(Last) (First)

ADDRESS ______

(Street)

______

(City) (Zip)

E-MAIL ADDRESS ______

CELL PHONE # (_____) ______HOME PHONE # (____) ______

DATE OF BIRTH ____/____/______MALE ____ FEMALE

TYPE: Please register for this golf season according to your age as ofDecember 31:

____ ADULTRESIDENT $35 (Age 18-61)

____ SENIORRESIDENT $22 (Age 62+)

____ JUNIORRESIDENT $22 (Age 12-17)

____ NON-RESIDENT $65 (All Ages)

____ OUT OF STATE$75 (All Ages)

RENEWALS: GOLF ID #______CHANGEMY PIN #______

NEW REGISTRATIONS: SELECT 4 DIGIT PIN # ______

By signing this form, I acknowledge that I am a domiciled resident of Bergen County, certify and affirm that the above information is true and I realize that any falsification is punishable by law NJSA 2C:28-3. I also agree to abide by all rules and regulations set forth by the Bergen County Department of Parks and understand that management reserves the right to revoke the registration and playing privileges for any violation.

SIGNATURE ______DATE______

Revised 2014

RENEWALS:
May be done thru the mail or in person at any golf course.
If renewing by mail, send the following items:
__ Completed form
__ Original golf ID card*
__ Copy of your driver’s license**
__ Stamped self-addressed envelope
__ Check payment (Make check payable to
Bergen County Department of Parks)
If your age category has changed from last year, you must renew in person to have a new card printed.
*If you have lost your golf card, you must renew in person and there will be an additional $10 replacement card fee.
If renewing in person, bring the following to any golf course:
__ Completed form
__ Driver’s License with photo**
__ Golf ID card*
__ Cash or credit card payment (Visa or MC) /

NEW REGISTRATIONS:

Must be done in person. Bring the following items to any golf course:

__ Completed form
__ Driver’s License with photo**
__ Cash or credit card payment (Visa or MC)
**In lieu of driver’s license must provide two of the following documents with name and address listed: Current Deed to Residence, Current Lease to Residence, Current Residential Property Tax Bill, Current Utility Bill or Current W-2 or 1099 Statement and photo ID.
**Juniors need copy of birth certificate & school ID, report card or library card and resident parent must show driver’s license.

RESIDENT DISABILITY REGISTRATIONS: ADisabled Golf ID card with discounted greens fee available if 100% disabled and currently receiving disability benefits from Social Security. A Social Security Awards letter is required to qualify.

New disability registrations can only be issued at the Golf Office. Only previously issued disability registrations may be renewed at the golf courses; however, any changes in age category will require in-person renewal at the Golf Office.