Buggy Submission Form

By submitting this form, you agree to comply with the SLCGA Transportation Policy and you consent to SLCGA processing and storing the personal data contained herein for the purpose of administering competitions and processing your request to use a golf buggy.

Following an initial doctor/physio letter for a request to use a golf buggy in competition this self-assessment form can be used for subsequent requests to continue to use a golf buggy in a Suffolk Ladies competition. It will be valid for 1-5 year. Please note that any expense incurred for completion of this form and submission to the SLCGA is the responsibility of the Player. The SLCGA have no responsibility for the availability or cost of a buggy and, where there are only a few buggies, it will be on a first come/first served basis.

Name*

First NameLast Name

Home Club*

requests the use of a golf buggy for SLCGA events as a reasonable adjustment for a disability within the meaning of the Equality Act 2010.

Please complete and return this form online or to The Secretary:

e-mail: secretary@suffolkladiesgolf.org.uk

post: c/o 42 Glanville Place, Kesgrave, Suffolk IP5 1NG.

Please note that we require all the questions below to be answered. Select as appropriate:

Email for confirmation of Entry*

example@example.com

1) Do you experience symptoms of, or suffer with, a physical or mental impairment? *

2) Does your impairment have a substantial adverse effect on your ability to carry out day to day tasks?*

3) Does your impairment have a substantial adverse effect on your ability to walk long distances, carry golf clubs, or otherwise play a round of golf? *

4) Have you experienced symptoms of the impairment for a period of over 12 months? *

5) Is your impairment permanent or temporary?*

6) If your impairment is temporary, is it expected to last longer than 12 months in total? *

STATEMENT OF TRUTH: I confirm that the information contained in this document is, to the best of my knowledge, a true and accurate reflection of my medical circumstances as of the date of this form. *

Date

Suffolk Ladies County Golf Association