22nd Annual BC SENIORS GAMES

BC SENIORS GAMES 2009 - Zone # 3 - GOLF

(Please Print) *Indicates required information
Did you participate in the playdowns and/or the Games during the last 2 years? Yes____ No____

Preferred First Name* ___________________________________

Last Name* ___________________________________________

Preferred Phone #( ) __________________________

Optional Phone #( )___________________________

Home Address:

City ______________________________________________

Postal Code _________________

Mailing Address (if different)

__________________________________________________

City ____________________________________Postal Code _________________

e-mail Address ______________________________________________________

Gender: M__ F__ *Birthdate: MM_____ DD_____ YYYY _______ Age group:________

Index*:_____________________________ Event*:A___ (0-24.3) or B___ (24.4-40)

Those participating in the BC Seniors Games are asked to fill in the following:

*I will need transportation while at the games: Y___ N___ Event: GOLF

*I will be attending the Games as:Participant___ Non-Participant___ Substitute__

*Choice for Lunches: Regular____ Vegetarian____ Diabetic____ Gluten Free____

*Medical Information: Emergency Contact Name:

___________________¬¬¬¬______________ Relationship: __________________

Phone # (where they can be reached) (___) _________________________

List any existing medical conditions that you will want those assisting you in a medical emergency to know about. i.e. medications, drug reactions, allergies, pre-existing conditions, joint replacement, contact lens, etc.

_______________________________ _________________________________

FOR CO-ORDINATORS OR REGISTRARS USE ONLY:

Zone Membership # 03-_____________]

Zone 3 Golf Co-ordinator_________________] BCSG 2008 Card issued: Y__ N__ ]
(initials)

PAYMENTS REQUIRED:
Membership Fee ($15.00) paid _________

PLAYDOWN: FINALS:
Green Fee ($28.00) ________ Participant Fee($50.00) paid ____________

Golf Surcharge ($65.00) paid ____________

TOTAL RECEIVED ____________________

TOTAL RECEIVED ____________________

OTHER:
Non-Participant($35.00 fee + $15 membership) paid ____________

Substitute Fee ($15.00 membership) paid ____________________

* Please note that membership in the BC Seniors Games Society, which requires a
yearly membership fee of $15.00, is required along with the signed copy of the
waiver below in order to participate in the BC Seniors Games. This also entitles
the member to participate for any Zone Play-off that may be needed. There will be further fees for those who go on to the games.

WAIVER FORM:
A Membership Application/Waiver Form must be signed by all members as a requirement of our Risk Management and as a condition of entry in Zone tryouts, Zone playoffs, and the BC Seniors Games themselves. The waiver forms will be kept within the Zone as part of the membership records for that Zone.

Participant Hold Harmless Clause:
Participant information is collected under the authority of the BC Seniors Games
Society as collector and custodian of this information. This information will be
provided to the Society. The information provided will be used to determine the
eligibility to participate in the 2009 BC Seniors Games. On confirmation of
eligibility the information will be used to arrange eligibility insurance coverage with respect to voluntary participation of registered participants in the 2009 BC Seniors Games. The name, hometown and sport of registered participants will be provided to media outlets and available on the BC Games Society, Richmond 2009 BC Seniors Games Society, and the BC Seniors Games Society websites. The name, address and image of registered participants may be used in non-commercial promotion/development of sport, the BC Games and/or the BC Seniors Games. The names, addresses and image of Games participants may be provided to the Premier and the Minister responsible for the Games. For questions about the collection and use of this information, please contact Laura Wilson at the BC Seniors Games Society - (250) 385-3610 or bcsgs@shaw.ca. As a condition of entry into, or volunteering at, the BC Seniors Games, it must be understood that the participants and volunteers enter entirely at their own risk, and will not hold the BC Seniors Games Society, the Richmond 2009 BC Seniors Games Society, the Province of British Columbia, and the BC Games Society, their staff, agents, and volunteer workers responsible for injury, loss or damage occurring during the 2009 BC Seniors Games. Participants and volunteers agree to release, discharge and undertake not to commence action
against the Richmond 2009 BC Seniors Games Society, the BC Seniors Games
Society, the Province of British Columbia, and the BC Games Society from any and
all claims and causes of action, or liability of any kind whatsoever for injuries, property damage, or death, which in any way results from participating or volunteering in the Richmond 2009 BC Seniors Games. The Richmond 2009 BC Seniors Games Society, The BC Seniors Games Society, the Province of British Columbia, and the BC Games Society do not assume responsibility for loss of wages, medical, dental, or hospital care for athletes, coaches, managers, chaperones, officials or volunteers during the 2009 BC Seniors Games.

I have read, understood, and agree to all of the above.

Signed:_____________________________________________________________
(Signature required here)

Date: _______________________________________