Department of Parks and Recreation
Derrick France, Director
Parks and Recreation
247 Fore Dr., Suite 201
Gate City, VA 24251
Phone: 276-452-2442
Fax: 276-452-4554
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Scott County Recreation Department
2021 Summer Golf Clinics - Registration Form
Name(s):   Date of Birth:

Address:   School:

City:   State:   Zip:

Home Phone:   Work Phone:



June 9, 16, 23, 30; July 7

Cost(s) are $45 per person for the entire summer; $65 per family

MAIL FORM & PAYMENT TO: SCRD, 247 Fore Dr. Suite 201 GATE CITY, VA 24251.


Boys & Girls Ages 8-10; 9:00-10:30 a.m.
Boys & Girls Ages 11-14; 10:30-Noon

In consideration of the acceptance of my application for this activity, I hereby covenant not to sue the organizers, the promoters, sponsors, the officials, the County of Scott, the Scott County School System or any of their employees, agents or representatives involved with this activity and I forever waive, release and discharge said individuals and entities and each of them from any and all claims for personal injury or property damage which I may have or which may subsequently occur to me as a result of my participation in this activity and I hereby agree to indemnify and save and hold harmless said individuals and entities and each of them from any loss, liability damage or cost they or each of them might incur due to my presence or participation in this activity.

It is expressly agreed that the forgoing not to sue, release, discharge, waiver and indemnity agreement is intended to be as broad and inclusive as is permitted by the laws of the Commonwealth of Virginia and furthermore binding on my heirs, executors and assigns.

I recognize that there may be difficulties involved with this activity and I certify that I am sufficiently physically fit to participate in such an activity and I have no physical limitations or restrictions which would prohibit my participation nor have I been advised by a physician that I have such limitations or restrictions.

The submission of this form indicates acceptance of the terms and conditions, that you agree to all the information stated on the form, and that all information submitted is correct.