REGISTRATION

$250 Player

$250 Hole Sponsor

$500 Bronze Sponsor

$ 1,000 Silver Sponsor

$1,500 Gold Sponsor

Attached is my donation check for $___________

payable to the Spina Bifida Association of Georgia

My check covers the following participants:

Name:______________________________
Address:____________________________
____________________________________
Phone:______________________________
Average Score or Handicap_____________

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Name:______________________________
Address:____________________________
____________________________________
Phone:______________________________
Average Score or Handicap_____________

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Name:______________________________
Address:____________________________
____________________________________
Phone:______________________________
Average Score or Handicap_____________

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Name:______________________________
Address:____________________________
____________________________________
Phone:______________________________
Average Score or Handicap_____________

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Credit Card Information

Mastercard

Visa

American Express

Account Number _______________________________

Expiration Date________________________________

Signature ____________________________________
(as it appears on credit card)

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Mail check and registration form to:

Spina Bifida Association of Georgia, Inc.
3355 Northeast Expressway, Suite 207
Atlanta, GA 30341
Phone (770) 454-7600
Fax (770) 454-7678