Thank you for your interest in going on a Round of a Lifetime. Please fill out the form below, if you have any questions please email Erik Fischer at erik@roundofalifetime.com

Applicant Information

Name

First Name

Last Name

Date of Birth

YYYY

Message

Gender

Phone

(###)

###

####

Occupation

Primary Language

Permanent Address

Is the applicant aware of his/her medical condition?

Yes

Physician Information

Doctor's Name

Hospital/Treatment Center

Office Address

Office Phone

(###)

###

####

Office Fax

(###)

###

####

Parent/Legal Guardian Information (If Under 18)

Name

Relationship

Permanent Address

Phone

(###)

###

####

Primary Language

Applicant Reference

Name

Relationship

Phone

(###)

###

####

How did you find out about Round of a Lifetime Foundation?

Round of a Lifetime Information

When was the applicant diagnosed with a congenital heart condition?

Please describe the applicant's prior experience and relationship with the game of golf:

Please describe the applicant's level of interest in playing an 18 hole round of golf at a world class course:

What is the applicant's golf skill level (or if applicable, handicap)?

Why is the applicant a great candidate for the Round of a Lifetime award?

Who is the applicant's favorite golfer?

Please explain the applicant's ability and/or restrictions for air travel:

Is the applicant enrolled in school of any kind? If so, what grade and what school?

Please disclose any other medical restrictions (i.e. physical restrictions, food allergies, travel restrictions, etc.)

Will the applicant require the use of a golf cart in order to play an 18-hole round of golf?

Yes

As of today, where did the applicant play his or her favorite round of golf?

Who would the applicant invite to play in his or her group if given a Round of a Lifetime?

What month/s of the year would the applicant prefer to take a Round of a Lifetime?

Are there any months that the applicant would be unable to take a Round of a Lifetime?

For a printable version of the application, please click here.

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Every Heartbeat Matters.

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Every Heartbeat Matters.