REQUEST TO USE A GOLF BUGGY ON THE BASIS OF A TEMPORARY CONDITION or a LONG-TERM DISABILITY

REQUEST TO USE A GOLF BUGGY ON THE BASIS OF A TEMPORARY CONDITION or a LONG-TERM DISABILITY - SELF CERTIFICATION
To be completed by the player and submitted in advance of the first competition to which it applies.
Name*

First NameLast Name
Club*
Address
Tel Number*
Email*
example@example.com
CDH Number*
The reason for making this request is that I have a (please select 1):*

short-term, temporary injury/conditiona disability within the meaning of Section 6 of the Equality Act 2010 - 'A person has a disability if they have either a physical or mental impairment and that impairment has substantial and long-term (more than 12 months) adverse effect on their ability to carry out normal day-to-day activities'
In the case of short-term, temporary conditions, please state the length of time that you require the permit for use in any NLCGA competition: blanks weeks/months.
By signing this document, I confirm that:
- The information provided is, to the best of my knowledge, a true and accurate reflection of my medical circumstances.
- My temporary injury/condition/disability adversely affects my ability to walk long distances, carry golf clubs or otherwise play a round of golf without the use of a buggy.
- I will inform the Secretary if my medical circumstances change.
- I understand that if any information contained in this document is found to be false or outdated, I may be disqualified from any event or competition that I have entered.
- I agree to comply with the provisions of the NLCGA Transportation Policy 2025.
- I consent to NLCGA processing my personal data for the purpose of fulfilling my request to use a golf buggy.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

REQUEST TO USE A GOLF BUGGY ON THE BASIS OF A TEMPORARY CONDITION or a LONG-TERM DISABILITY - SELF CERTIFICATION