2017 PROGRAM SCHEDULE
The First Tee of NH at Hanover Country Club
36 Hilton Field Road
Hanover, NH 03755
www.golf.dartmouth.edu
MONTH / SESSION DATE / TIME / SKILL LEVEL(Ages 7-14)
June / June 20, 21, 22 (Tu, W & Th)
Deadline to Sign Up: June 15th / 9am – 12pm / PLAYer/PAR
July / 11, 12 & 13 (Tu, W & Th)
Deadline to Sign Up: July 5th / 9am – 12pm / PLAYer/PAR
18, 19 & 20 (Tu, W & Th)
Deadline to Sign Up: July 13th / 9am – 12pm / PLAYer/PAR
August / 9, 10 & 11 (W, Th & F)
Deadline to Sign Up: August 3rd / 9am – 12pm / PLAYer/PAR
A cookout will be held at the end of session on Thursdays (Friday in August).
Today’s Date New Participant? □Yes □No Returnee? □Yes □No Participant Since /20____
Participation Consent Form completed by: □Mother □Father □Legal Guardian
Space is limited and will be filled on a first come, first served basis. Payment must be received to confirm your spot.
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Youth Information:
Name: Gender: □Female □Male
(First, Last)
Address: City: State:______ZipCode:
Age: ______Birth Date (____ /____ /______) School: School Grade Level*:
MM DD YYYY
*To help us measure the success of our program, please provide your child’s current average scholastic grade (A, B, C, D or F): ______
Parent/Legal Guardian:______Relationship:______
(First, Last)
E-mail Address:______Phone (W):______(H):______(C)______
I heard about The First Tee from: □Friend □TV/Media □Attended in-school program at:
I am registering through: □On my own □Rec Department: □Youth Organization:
Ethnicity: □African-American □Asian-American □Caucasian □Hispanic □Native-American □Pacific-Islander
□Other______ □I do not wish to respond
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Health and Emergency Information:
Please list any allergies, disabilities or other health issues that we should know about:______
______
Emergency Contact:______Relationship/Phone#::______
(if parent/guardian cannot be reached)
Alt Emergency Contact: Relationship/Phone#:______
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 First Tee Chapter representatives. I hereby give permission to the medical personnel selected by The First Tee Chapter representatives to secure any and all medical, hospitalization, dental, and/or surgical treatment. In event that such medical attention is needed from a healthcare provider, all costs shall be the responsibility of the parent or guardian.
Parent/Guardian Initials:______
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Golf Information:
Please Check: □ Right Handed □ Left Handed □ Don’t Know
Golf Clubs Needed? □ I will bring my own clubs □ I will need clubs provided (TFTNH has plenty available)
Amount of Golf Experience: □ None □Very Little □Moderate □Quite a bit □A lot
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The First Tee of New Hampshire at Hanover Country Club
36 Hilton Field Road, Hanover, NH 03755
603-646-2000
www.golf.dartmouth.edu
01/27/2017
2017 TFTNH at Hanover Country Club Program Registration and Permission Form
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Program Selection and Payment
COST OF SESSIONS / Per Child / Two (2) ChildrenPLAYer/PAR (ages 7-14)
3-day session
(includes cookout at end of session) / $235 / $425
Using TFTNH at Hanover Country Club Program Schedule below, please make your session selection(s):
SESSION DATES / TIME / # of Child/Children / COST*June 20, 21 & 22 (Tu, W & Th) / 9am – 12pm
July 11, 12 & 13 (Tu, W & Th) / 9am – 12pm
July 18, 19 & 20 (Tu, W & Th) / 9am – 12pm
August 9, 10 & 11 (W, Th & F) / 9am – 12pm
*See Cost Table above, All sessions are Non-Refundable*
Total Amount Due: Amount Paid:
I wish to make an additional donation to The First Tee of NH to help them attain matching funds ($5 min) Donation Amount $______
Payment Type: □ Check (make payable to Dustin Ribolini)
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Equipment: I understand that any golf equipment received for use is the property of The First Tee program, and may be returned at the discretion of The First Tee facility upon the termination of the participant’s involvement in the program. Parent/Guardian Initials:______
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Media Release: I hereby give The First Tee Chapter, Headquarters Office and participating agencies permission to use film, video tape and/or photographs of the above mentioned minor for lawful promotional or informational purposes. Parent/Guardian Initials:______
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Youth Name (please print):
I, the parent/legal guardian of the above named youth, give approval for participation in The First Tee sponsored activities. I assume all risks of injury whatsoever and agree to hold harmless The First Tee Chapter and Headquarters Office from claim(s) of any nature arising from any activity, including transportation, connected with The First Tee facility or program. This hold harmless agreement includes, but is not limited to, any claim due to injury proximately resulting from negligence of The First Tee Chapter or Headquarters Office, its employees, agents, LPGA and PGA Professionals, participating agencies, and volunteers. I consent to The First Tee Chapter and Headquarters Office communicating information regarding my child’s participation via the internet.
Parent/Guardian Signature: Date:______
Please Print Name: ______
Please make check payable to Dustin Ribolini and mail/drop off completed form to address below. Thank you!
The First Tee of New Hampshire at Hanover Country Club
36 Hilton Field Road, Hanover, NH 03755
603-646-2000
www.golf.dartmouth.edu
01/27/2017