MIDDLE ATLANTIC BLIND GOLF ASSOCIATION

MABGA

Application Form

Applicant's Name: _____________________     Date:  _______________

Address:     ___________________

                    ___________________

                    ___________________

 Phone:  ___________________     Date of Birth:  ______________

Physician's Name: _______________________

 Address: __________________________

                    __________________________

                    __________________________

 Phone: ___________________

1.     VISUAL ACUITY:

                                            Distance Vision

           WITHOUT CORRECTION                   WITH CORRECTION  

            Right Eye (OD)   ________                ___________

            Left Eye (OS)    _________               ___________

            Both Eyes (OU)   _________              ___________

2.    VISUAL FIELD LIMITATION:

            Central Vision:    ____________   

            Peripheral Vision:    ____________   

3.    Diagnosis:    ______________________

4.    Is the applicant legally blind?                Yes                No

5.    List golf experience:    _______________________________________

                                        _______________________________________

Physician's Signature: _______________   Date:  ________________