Black Bull Golf Resort

Black Bull Golf Resort – Junior Golf Camp Registration

Camp Fee: $175 (GST Included)

Please enter the details of the child registering for the camp.

First Name

Middle Name

Last Name

Gender

Male

Female

Other

Birth Date

School Name

Grade

Age

Child's Address

Street Address

Town/City

Province

Postal Code

Address Line 2

Country

Parent/Guardian #1 Contact Information

Some description about this section

First Name

Last Name

Parent #1 Address (If different)

Street Address

Town/City

Province

Postal Code

Address Line 2

Country

Cell Phone Number

Alt. Phone Number

E-mail

Parent/Guardian #2 Contact Information

Some description about this section

First Name

Last Name

Parent #2 Address (If different)

Street Address

Town/City

Province

Postal Code

Address Line 2

Country

Cell Phone Number

Alt. Phone Number

E-mail

Emergency Contacts (Alternate Pickup/Release)

Some description about this section

Emergency Contact #1

First Name

Last Name

Home Phone

Work Phone

Cell Phone

Email

Relation to Child

Emergency Contact #2

First Name

Last Name

Home Phone

Work Phone

Cell Phone

Email

Relation to Child

Authorized Pickup List

Please list those people (in addition to parents/guardians) who are permitted to pick up your child:

Authorized Person 1

Authorized Person 2

Authorized Person 3

Medical Release & Insurance Information

Some description about this section

Health Insurance Provider

Policy Number

Primary Physician

Physician Phone

Physician Address

Hospital Preference

Medical Problems / History

Please list any medical problems, including any requiring maintenance medication (i.e., Diabetic, Asthma, Seizures).

Is your child presently being treated for an injury or sickness, or taking any form of medication?

Yes

No

Sickness/Medication Explanation

Is your child allergic to any type of food or medication?

Yes

No

Allergies Explanation

Does your child require a special diet?

Yes

No

Special Diet Explanation

Terms & Authorizations

Some description about this section

Emergency Medical Authorization: I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.

Parent's/Guardian's Initials (Emergency Authorization)

Financial Responsibility: I understand that The Clubhouse will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.

Parent's/Guardian's Initials (Financial Responsibility)

Photo Release Agreement: I hereby give permission for my child to be photographed during Black Bull’s Junior Golf Camp. I understand the photos will be used to keep a journal of activities, to share on social media for promotional purposes including flyers, brochures, newspaper etc. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of Black Bull Golf Resort.

Parent's/Guardian's Initials (Photo Release)

Transportation Release: I hereby give permission for the transportation of my child for official Black Bull Junior Camp activities by modes of transportation agreed to by the camp organizers.

Parent's/Guardian's Initials (Transportation Release)

Liability & Refund Notice: Black Bull Golf Resort is not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. Children's’ photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician).

Printed Name of Parent/Guardian

Date

Select Time Slot

PAYMENT INSTRUCTIONS — $175.00 CAD

Step 1: Send Payment
Send $175.00 CAD per participant (GST included) by Interac e-Transfer (EMT) to patricia1oconnor@yahoo.ca. Include the participant’s name in the transfer message.

Step 2: Submit Your Registration
After sending your payment, return to this form and click SUBMIT to complete your registration.

Step 3: Registration Confirmation
Your registration will be confirmed once your payment has been received and verified.

I hereby agree to all terms, releases, and authorizations stated above as parent/guardian.

	Medical Problem	Required Treatment	Call Paramedic? (Yes)	Call Paramedic? (No)
Condition 1
Condition 2
Condition 3

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