Charity Golf Reg. Form

Sponsorship and Team Registration Form NAIFA-CV 13th Annual Charity Golf Tournament to benefit the Charlottesville Free Clinic May 23, 2011— Glenmore Country Club E S VI LE FRE E registration, golf team registration is on the reverse side. L We have several opportunities to sponsor and support the 13th Annual Charity Golf Tournament to benefit the Charlottesville Free Clinic. See below for sponsorship TT C L I NI C A CH RL O Sponsor contact Information Name/Title _________________________________________ Company Name ________________________________________ Address _____________________________________________ City/State/Zip___________________________________________ E-mail _______________________________________________ Phone ________________________________________________ Sponsorship Opportunity q Dinner Sponsor — $2,000 q Special Sponsor — $1,200 q Hole Sponsor — $150 q We would like to provide giveaways for the player goody bags —­ total 125 items. q Donate to silent Auction/Raffle q Team Only — see reverse side of this sheet for team registration Silent Auction/Raffle Donation Description of item ____________________________________________________________________________________________________ Restrictions ____________________________________________________ Expiration Date ________________________________________ Fair Market Value of Donated Item $_____________________________ q Please check here if you need the Charlottesville Free Clinic to pick up item. RECEPTION/Dinner/Silent Auction only — $75 per person Another great way to participate in this event is to join us for our reception, dinner, and silent auction. We will have exciting ,auction items, great food, and fun company. If your are interested in the evening event, please fill out the registration area below. Name ______________________________________________ Name _________________________________________________ Address _____________________________________________ Address ________________________________________________ E-mail _______________________________________________ E-mail _________________________________________________ Phone ______________________________________________ Phone ________________________________________________ Please see team registration and payment options on reverse side of this sheet 2  Team registration for foursomes includes: range, golf, cart, goody bag, raffle and hole prizes. Followed by a silent auction and dinner for each participant plus a spouse or guest. If you would like to attend as a dinner guest only and participate in the silent auction please fill in the information under dinner guest only. Team Information ($700 per team, $175 per golfer) #1 Golfer Name ____________________________________ #3 Golfer Name ____________________________________ Address _____________________________________________ Address _____________________________________________ _____________________________________________________ _____________________________________________________ E-mail _______________________________________________ E-mail _______________________________________________ Phone ______________________________________________ Phone ______________________________________________ USGA Handicap/Home Course ________________________ USGA Handicap/Home Course ________________________ Dinner Guest Name __________________________________ Dinner Guest Name __________________________________ #2 Golfer Name ____________________________________ #4 Golfer Name ____________________________________ Address _____________________________________________ Address _____________________________________________ _____________________________________________________ _____________________________________________________ E-mail _______________________________________________ E-mail _______________________________________________ Phone ______________________________________________ Phone ______________________________________________ USGA Handicap/Home Course ________________________ USGA Handicap/Home Course ________________________ Dinner Guest Name __________________________________ Dinner Guest Name __________________________________ Payment q q Check is enclosed. (Please make checks payable to Charlottesville Free Clinic.) Please charge my credit card ( Amount q Visa or q MasterCard) $__________________________________________________ Card Number _______________________________________________ Expiration Date ________________________________________ Signature/Date _______________________________________________ Zip Code of billing address _______________________________ q I will pay on the day of the tournament. Questions? Contact CFC Development Assistant Kelly Durkin at 434.295.0008 or kelly@cvillefreeclinic.org. Return registration form Please return this registration form and check (if applicable) to Charlottesville Free Clinic in enclosed reply envelope. For more information please view cvillefreeclinic.org/golf. Registration forms are due by May 16, 2011.