Registration Form

Hotel Information

Registration Form

red color - denotes required fields

First Name:

Last Name:

Title:

Company:

Address1:

Address2:

City:

State Code:

Zipcode:

E-mail:

Daytime Phone:

Secondary Phone:

Emergency Contact

Name:

Phone:

Player Fees and Sponsorships

For sponsorship details, click here.

Player Packages/Sponsorships:

Silent Auction Item Contribution:

Dinner only $150/person:

Name(s) of Dinner Guests:
(separate names by commas)

Please specify any special diet requirements that need to be accommodated.

If Registering Multiple Players, Provide Player Names & Additional Information:

URSA & NOVA SPONSORS

You will be Personally Contacted for Additional Player Information

Player 1:
Email:
Phone:
Handicap:
Shirt Size:
Gender:

Player 2:
Email:
Phone:
Handicap:
Shirt Size:
Gender:

Foursome preference is not guaranteed

Player 3:
Email:
Phone:
Handicap:
Shirt Size:
Gender:

Player 4:
Email:
Phone:
Handicap:
Shirt Size:
Gender:

Payment Option:

All Credit Card fields are required when paying with Credit Card.

Credit Card Type:

Card Holder's Name:

Credit Card Number:

CCV#:

[ What is this? ]

Expiration Date:

Check for same as above address:

Billing Address1:

Billing Address2:

Billing City:

Billing State:

Billing Zipcode:

Paying by Check?
Final Payment is Required within 14 Days of Registration Date

After successfully completing this form you will receive a registration number (it will also be e-mailed to the e-mail address provided in this form). Please include the registration number on your check made payable to �Skip Viragh Charities� and mail your payment to:

Skip Viragh Charities
Attn: Holly Marshall
Suite 500
9601 Blackwell Road
Rockville, MD 20850

Comments - Questions - Special Requests:

Total Purchase: