PDGA USA Academy Online Registration

Registration

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Welcome to PDGA USA SFS and thank you for your interest in our top-quality classes! The following registration form must be completed and the Registration Fee along with the Class Fee must be paid in order to secure the spot in the class you selected. Please call our main office should you have any questions regarding this form or any of our classes: (562) 229-1927

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name*

Family Information

Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Additional Info

Emergency Contact Info*

Health Insurance Carrier

Contact #1

First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Who is your employer?

Employer

Employer Phone

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

Anyone registering or taking a class for the first time must complete and sign the full 'Payment Requirement Contract,' 'Release of Liability', ' Agreement to treat a Minor' A $40 Annual REGISTRATION FEE will be charged to your credit card once Registration is complete. THIS FEE IS NON-REFUNDABLE. Please inquire at the front desk for Registration Fee Upgrade Options.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

PDGA USA SFS Payment Requirement Contract

1. There are no refunds of any kind
2. Tuition is based on monthly, not hourly.
3. Tuition is due by the 1st of every month. If tuition isn't paid by the 3rd, your child will be dropped from the class. If you choose to re-enroll your child there will be a $10 re-enroll fee, depending on the level of registration the student may have to re-register as well.
4. $15 fee will be charged for the first bounced check. On the 2nd bounced check, tuition will have to be paid by cash
6. All PDGA classes are based on 4 classes per month. PDGA doesn't charge for the fifth class in the month, PDGA will close on holidays and will not give discount for the missed class.
7. Student must be current in monthly fees to have a make-up class.
8. One make up class will be allowed every month. Make up classes will not be allowed to roll over to the following month. Please make arrangements by calling the office at 562-229-1927
9. To end autopay, you must email us at info@pdgausa.com by the 15th of the month, If we do not receive email in writing you will be responsible for full tuition for the following month. No Exceptions. If you have your bank deny the transaction you will be subject to collections for the amount owed and placed in problem account at PDGA.
10. If 1 class is attended during the month FULL tuition is due for that month, NO EXCEPTIONS

I've read the above and agree.

Release of Liability Waiver

It is expressly agreed that all use of PDGA USA, Inc.'s property, equipment, services, programs and activities, and participation in, or a spectator to, any programs conducted within or on the property of PDGA USA, Inc., and any transportation provided by PDGA USA, Inc. shall be undertaken by me, or my child, or my legal ward at my/his/her sole risk, and PDGA USA, Inc. shall not be liable for any bodily injuries--including catastrophic injury, paralysis and even death--or any loss or damage to my/our/their person or property, or to be subject to any claim, demand, injury or damages whatsoever, including, without any limitation, those injuries and/or damages resulting from acts of active or passive negligence on the part of PDGA USA, Inc., its employees or agents. I, for myself and on behalf of my children, my executors, administrators, legal wards, heirs, assigns and successors, do hereby expressly forever release and discharge PDGA USA, Inc., its employees, officials, agents, assigns and/or successors from all such claims, demands, injuries, damages, actions or causes of actions whatsoever. It is agreed that I have read and understand all policies and regulations associated with my use of any PDGA USA, Inc. property or equipment or participation in any PDGA USA, Inc. program, and agree to abide by all policies thereof. Violations of any PDGA USA, Inc. policy or regulation may result in revocation of this pass. Please sign below to acknowledge that you have read and understand this Waiver and Release of Claims.

I've read the above and agree.

Authorization to treat a minor

I (we), the undersigned parents, parents, or legal guardians of a minor, do hereby

Authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medicine Practice Act or a dentist licensed under the provision of the Dental Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital from the State of California Department of Public Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power to render care which the aforementioned physician in the exercise of his best judgment may deem advisable. In the event of any emergency, I understand that my child may be transported to the nearest emergency facility. I understand that any cost incurred for such emergency treatment shall be my sole responsibility. It is understood that effort shall be made to contact the undersigned prior to treatment of the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached.

This authorization is given pursuant to the provisions of section 25.8 of the Civil Code of California.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State

Zip*