2024 Ernie Els #GameON Autism Golf Clinic Participant Registration Which regional Golf Challenge event are you attending?(Required) The Club at Ruby Hill, Pleasanton, CA - Monday, Aug. 26th Wethersfield Country Club, Wethersfield, CT - Monday, Sept. 9th Chicago Highlands Club, Westchester, IL - Monday, Sept. 16th River Bend Gold & Country Club, Great Falls, VA - Monday, Sept. 23rd TPC Las Vegas, Las Vegas, NV - Monday, Oct. 14th Princess Anne Country Club, Virginia Beach, VA How did you hear about the clinic?(Required) Participant's Name(Required) First Last Participant's Age(Required)Participant's Approximate Height Participant is:(Required) Right Handed Left Handed Participant's golf skill level:(Required) First Day Beginner Intermediate Advanced Participant communicates:(Required) Verbally With pictures With a device Sign language Other Participant's receptive language capability:(Required) Full sentences 1-2 words Gestures only Other Participant's expressive language capability:(Required) Full sentences 1-2 words Gestures only Other Will the participant come with a support aid or 1:1 companion?(Required) Yes No Please note any specific behaviors of concern (e.g. elopement, stimming, self-injurious behavior, etc.) so that golf instructors can best be prepared. Please note this is not to exclude anyone but rather to ensure coaches are best prepared with knowledge of participants' needs.Please note the participant's dietary restrictions and allergies below.Please provide any additional information below.Parent/Guardian's Name(Required) First Last Parent/Guardian's Email(Required) Parent/Guardian's Phone(Required)RELEASE, WAIVER OF LIABILITY And ASSUMPTION OF RISK(Required) I agree.I understand that the game of golf involves risks and dangers that may subject me to serious bodily injury, which may ultimately be fatal. The risks and dangers associated with golf may be caused by my own actions or inaction, or by others participating in the activity. All the possible causes and consequences of participation may not be known to me nor readily foreseeable at this time. My signature on this form demonstrates that I believe I understand the nature of golf activities and that I am in good health and in proper physical condition to participate. I further agree and warrant that, if at any time I believe the activity to be unsafe for me, I will immediately discontinue participation. I fully accept and assume all risk and all responsibility for losses, costs, liability, injury, and damages I may incur as a result of my participation in golf activities at the Els Center of Excellence. Knowing that participation in golf activities entails various risks, and in consideration for being permitted to participate, I release the Els for Autism Foundation, its successors, and assigns from any and all costs, claims, actions, and liability that may arise in connection with my participation in their golf programs. I further agree to indemnify and hold harmless the Els for Autism Foundation, its employees, and contractors for any and all claims arising as a result of my participation in golf activities or any activities incidental thereto, wherever, whenever, or however, they may occur. VIDEOGRAPHY/PHOTOGRAPHY/AUDIO RELEASE CONSENTVIDEOGRAPHY/PHOTOGRAPHY/AUDIO RELEASE CONSENT I have read and understand the below statement.I understand that photography/audio/video recordings of my child and/ or myself are at no extra cost to me and that I may request to view them. This and the nature of the images and/or recording procedures have been explained to me. I understand that the images and/or audio records are confidential material and will not be used without my specific consent. I understand that I may withdraw my permission by written request at any time. Please choose one:(Required) I give CONSENT for my child’s or my own image and/or voice to be used for educational, training, and research purposes (e.g., national/international conferences or trainings/conferences). I DECLINE to give consent for my child’s or my own image and/or voice to be used for educational, training, and research purposes (e.g., national/international conferences or trainings/conferences). Employees/staff/Contractors of the Els for Autism Foundation may use these photographic images, video segments, or audio segments for reasons other than therapeutic purposes, including dissemination on social media.Please choose one:(Required) I give CONSENT for my child’s or my own image and/or voice to be used for publication purposes (e.g., textbooks, journal articles, or conference publications) I DECLINE to give consent for my child’s or my own image and/or voice to be used for publication purposes (e.g., textbooks, journal articles, or conference publications) Please choose one:(Required) I give CONSENT for my child’s or my own image and/or voice to be used for fundraising purposes. I DECLINE to give consent for my child’s or my own image and/or voice to be used for fundraising purposes. Please choose one:(Required) I give CONESNT for my child’s or my own image and/or voice to be used by commercial and/or non-profit entities associated with the Els for Autism Foundation and/or the Els Center of Excellence whose purpose is to disseminate information about the School, the Foundation’s events and programs, and the Centers’ facilities. I DECLINE to give consent for my child’s or my own image and/or voice to be used by commercial and/or non-profit entities associated with the Els for Autism Foundation and/or the Els Center of Excellence whose purpose is to disseminate information about the School, the Foundation’s events and programs, and the Centers’ facilities. If you have further questions about the information on this form, you may contact olivia.butler@elsforautism.org.
