Student Name *

First Name

Last Name

Primary Emergency Contact *

First Name

Last Name

Phone *

(###)

###

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Secondary Emergency Contact *

First Name

Last Name

Phone *

(###)

###

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Guardian Responsible for Pick-up *

First Name

Last Name

Image Consent *

H. Haney Golf Academy may at times take pictures during lessons or at times when trophies or awards are being presented. HHGA may display these pictures online or in various promotional and printed materials. We would like for you to be aware and comfortable with every action that involves your children. If you would or would NOT like your child’s picture used, please indicate below. Can HHGA use your child’s picture?

Yes, you may use my child's picture

No, DO NOT use my child's picture

Participation *

I understand the cost of the program is $60 per month. A $20 registration fee is due before the first class. Your child will be considered enrolled in our program upon payment of the registration fee and you will be responsible for the monthly payment until we are notified in writing of your child’s withdrawal. While my child is attending H. Haney Golf Academy’s After School Program, I acknowledge and assume all risks on their behalf and accept personal responsibility for any injury or damages that may occur. I release, waive, discharge and covenant not to sue H. Haney Golf Academy owners, management, agents, other participants and owners of the premises used to administer the program. I have read this waiver and release form and all disclosures and I am signing this form voluntarily. Distribution of this form through official district or school channels does not imply endorsement or support from Lexington - Richland 5 or any school therein.

I understand