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

Please fill out the following information regarding the applicant / patient.

Name

First Name

Last Name

Date of Birth

YYYY

Gender

Phone

(###)

###

####

Occupation

Primary Language

Permanent Address

Is the applicant aware of his/her medical condition?

Yes

Primary Physician or Cardiologist Information

Physician / Cardiologist Name

Name of Office, Hospital or Treatment Center

Office Address

Office Phone

(###)

###

####

Office Fax

(###)

###

####

Parent/Legal Guardian Information (If Under 18)

Name

Relationship

Permanent Address

Phone

(###)

###

####

Primary Language

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

The following questions are designed to provide us with a better sense of what our applicants and award winners have had to endure as it pertains to their heart health history and to ensure that what we are offering is safe. We will respectfully ask that if being considered for award, the applicant’s physician or cardiologist sign off on this information as well. This information will be kept strictly confidential unless a person or family would like their story told in our literature or on our website after being awarded. While we may describe diseases and procedures pertinent to our candidates, no names are attached to these details unless desired by candidate.

Diagnosis, and ballpark date of diagnosis.

Has the applicant had any surgery? Please list.

Has the applicant had any cardiac procedures? Please list.

How many days, if any, has the applicant been hospitalized due to the diagnosis?

Is the applicant on medications for his/her heart condition? Please list.

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

Yes

Please disclose any other medical restrictions that would apply if awarded (i.e. physical restrictions, air travel, food, etc.)

Additional Questions

Please describe why the applicant a great candidate for the Round of a Lifetime award.

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

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

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

Who is the applicant's favorite golfer?

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

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

Who might the applicant invite to play in his or her foursome 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?

Is there anything else you would like us to know about the applicant and his or her story?

Please click the Submit button below to complete your application submission!

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