Name: _______________________________________________________________________________________________________

Age: ________________________________________________________________________________________________________

T-shirt Size: (______)_______-___________

Email: _______________________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

Home Phone: (______)_______-___________

City: ________________________________________________________________________________________________________

State: _______________________________________________________________________________________________________

Zip: _________________________________________________________________________________________________________

Emergency Contact: __________________________________________________________________________________________

Relationship: _________________________________________________________________________________________________

Phone Number: (______)_______-___________ Cell Phone: (______)_______-___________

Medical Authorization Form
I certify that in the event that an emergency medical caremust be rendered to my child, and the above persons cannot be contacted, the required parental consent may be given by an authorized member of the teaching staff. I do hereby waive, release and discharge Brian Kirk Golf Schools, its officers, staff, employees and agents, and the facility of any and all rights and claims for damages resulting from injury of person or property during camp activities.

Parents Name: __________________________________________________________________________________________________

Signature:_______________________________________________________________     Date:____________

Circle One

Session 1   | Sessions 2

Mail completed entry to
Eagle Creek Golf Club Attn: Ben Heaver 8802 West 56th Street Indianapolis, IN 46234

Make Checks Payable to: Brian Kirk Golf Schools