2026 Moving Montgomery Forward Golf Initiative Registration Form
Fill out the form carefully for registration and if you have questions email quincyleonard@leogolfacademy.com or call 334-721-4536
Participant’s full legal name
*
First Name
Middle Name
Last Name
Birth Date
*
Please select a month
January
February
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Month
Please select a day
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Day
Please select a year
2026
2025
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1921
1920
Year
Gender
*
Please Select
Male
Female
N/A
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary E-mail
example@example.com
Parent Mobile Number
*
Phone Home Number
Parent Work Number
Participant's School
*
Grade Level
*
Please Select
6th Grade
7th Grade
8th Grade
Parent/Legal Guardian name and Relationship to Participant
*
Number of People in your household
*
Number of Children under age 18
*
Number of Children in household participating in MMFGI Activities
I verify that the above information is accurate
*
I agree
Medical Information
Primary care physician’s name
Physician’s phone
Please enter a valid phone number.
Physician’s Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
INFORMATION NEEDED ABOUT PARTICIPANT (Required)
*
Does the participant have any chronic health problem or illness?
Does he or she have any acute illness now?
Is the participant taking any medications for treatment of a medical problem?
Does the participant have any allergies to medication or local anesthetics?
Does he or she have any allergies?
None
INFORMATION NEEDED EXPLANATION
Please disclose any other disabilities or special needs your child has, that could affect their ability to have a positive experience.
Date of child’s last tetanus shot
-
Month
-
Day
Year
Date
HEALTH INSURANCE INFORMATION (Strongly Encouraged):
Policy holder’s name and relationship to participant
Policy holder’s address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please attach a photocopy of both sides of your insurance card (preferred)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Insurance company phone number
Please enter a valid phone number.
All policy numbers (please identify)
If you have HMO insurance, please list emergency treatment authorization phone number
Please enter a valid phone number.
Employer’s Name
Employer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
(Required)Official Medical Treatment Authorization. I recognize that while attending this program, medical treatment on an emergency basis may be necessary for my child, and I further recognize that volunteers or staff overseeing the program may be unable to contact me for my consent for emergency medical care. I do hereby consent in advance to such emergency care, including hospital care, as may be deemed necessary under the circumstances and to assume the expenses of such care. I also authorize the medical facility to release any and all information required to complete insurance claims and also authorize insurance payment directly to the medical facility.
*
I agree
I have read and agree to the entire registration form.
*
Submit
Should be Empty: