May 14, 2010 • Golfer Registration Form
Return form by faxing to 727-849-0942 or by mailing to
Gulfside Regional Hospice ATTN: Wyn Dale
6117 Trouble Creek Rd. • New Port Richey, FL 34653 I am registering as a(n):
❒ Individual ❒ Part of Foursome
Preferred Foursome (please list team members if applicable)
Player #2 Player #3 Player #4
Name_________________________________________________________________________ Address_______________________________________________________________________
Phone_______________________________ Email _________________________________ Shirt Size (please circle): S M L XL XXL XXXL
❒ I will be unable to play, but would like to make a contribution. Enclosed is my donation of: $__________
Payment Form
❒ Individual Registration ($200) ❒ Foursome Registration ($750)
Method of Payment (make checks payable to Gulfside Regional Hospice)
❒ Check ❒ MasterCard ❒ Visa ❒ AmEx
Name on Card ______________________________
Credit Card # _______________________________ Expiration Date ____/____
Billing Zip Code _____________________ Security Code (on back of card) ________ Amount Applied to Card $____________ Signature _________________________
WAIVER-Indemnification Agreement
I hereby waive all claims against Gulfside Regional Hospice, sponsors, Lake Jovita Golf & Country Club or any personnel for any injury I might suffer at
this event. I attest that I am physically fit and prepared for this event. I give permission to be photographed, videotaped, or interviewed during the golf
tournament. This material may be used for future publicity of Gulfside Regional Hospice, Inc., including news media and potential funding resources.
Signature __________________________________________ Date_____________________