College Coaches Corner Registration

Student Information

Student Name *

First

Last

Date of Birth *

Month/Day/Year

Email Address *

Cell Phone Number *

Home Phone Number (if applicable)

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Student Gender *

Country of Origin *

Current City Living In *

Year Student Started Training at The Mike Bender Golf Academy *

What Instructor do you train with? *

Upload your Headshot/Profile Photo here *

Parent/Guardian Information

Parent/Guardian Name *

First

Last

Relation to Student *

Parent Phone Number *

Parent Email Address *

Academic Information

Current GPA *

Anticipated Graduation Date (Month/Year) *

School Name *

School Address *

Address Line 1

Address Line 2

City

State

Zip Code

Do you Currently play high school golf? *

Yes
No
I am Not in High School yet

If Yes, Please list your High School Golf Coach's Name (first, last) below:

If Yes, Please list your High School Golf Coach's Email Address below:

SAT TOTAL Score (If not applicable, write "N/A") *

SAT Math Score (If not applicable, write "N/A") *

SAT Reading Score (If not applicable, write "N/A") *

SAT Writing Score (If not applicable, write "N/A") *

ACT Score (If not applicable, write "N/A") *

Area of Intended Study In College (If unknown, write "Undecided") *

Golf Performance Information

Current Junior Golf Scoreboard Rank *

Highlights & Honors *

Please use the following format - "Year Accomplished, Name of Honor or Explanation of Highlight"

Stroke Averages & Accompanying Year *

Ex: 2017, stroke average 73

Playing Record - Include Tournament Name, Date, Score and Result for each tournament listed. *

**Please Number Each tournament Listed

Upcoming Schedule

INCLUDE DATE OF EVENT, NAME OF EVENT, LOCATION OF EVENT

Payment Information

I have chosen the following payment option *

YEARLY - $200/yr. paid in full at time of registration
MONTHLY - $20/mo. paid on the first of every month - A Credit Card must be put on file for this payment option*
I am currently enrolled in the Mike Bender Elite Golf Academy

Our Academy Receptionist will call you for payment upon submission of this form.