Register Today for

Southern Deaf Golf Camp

Print and Mail or Fax to DHHS.

NAME:_________________________________AGE:______

ADDRESS:________________________________________

CITY:______________________STATE:____ZIP CODE:____

PHONE:(HOME)____/__________(WORK)____/__________

EMAIL:______________________________

HEALTH CONCERNS: (ALLERGIES ETC...)______________

PREFERRED SESSION:    JUNE 13     [9-11]     [11 -12]      [1 - 3]

(CIRCLE ONE)                      JUNE 14     [9-11]     [11 - 12]     [1 - 3]

CAMP FEE $15:  ___CASH/CHECK/MONEY ORDER

GOLF SHIRT SIZE

(Check one)

YOUTH        ADULT

_____SMALL_____

_____MEDUIM_____

_____LARGE_____

_____XL_____

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