Ernie Els #GameOn Autism® Golf Clinic Registration

Which regional Golf Challenge event are you attending?(Required)

Participant's Name(Required)

First Last

Participant's Date of Birth(Required)

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

Please note the participants 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)

VIDEOGRAPHY/PHOTOGRAPHY/AUDIO RELEASE CONSENT

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.