*1.First and Last Name(Required.)

*2.Title(Required.)

*3.Employer(Required.)

*4.Address including City, State, and Zip(Required.)

5.Phone

*6.Email(Required.)

*7.Select Contribution Level: A minimum contribution level of $250 PER PERSON made payable to the NCHCFA/PAC is required to attend this event. This contribution DOES NOT include hotel, golf, food, or spa fees. Qualifying contributions may be made anytime between 1/1/22 and 9/16/22.(Required.)

$5,600 Chair's Circle (Listed as a major sponsor with signage during the buffet lunch, reception,

$2,800 Leadership Club (Includes recognition at the awards dinner)

$1,000 Capitol Club (Includes recognition at the awards dinner)

$500 Supporters Club

$250 Friend

*8.Select Payment Method for NCHCFA/PAC Contribution: Reminder, only personal checks or personal credit cards will be accepted. No cash, money order, or corporate contributions to the PAC will be accepted.(Required.)

Personal Check: Mail to NCHCFA/PAC 5109 Bur Oak Circle, Raleigh, NC 27612

Credit Card Payment Online (link here) 

Contribution has already been made (qualifying contributions of $250+ made between 1/1/22 and 9/16/22).

*9.Select Your Attendance Package: Golf/Spa fees are included with lodging packages.  If you are not staying at Pine Needles, you must pay your green fees to the Mid Pines Golf course separately. The package prices DO NOT include the required NCHCFA/PAC donation of $250+. Please DO NOT send payment for these packages to NCHCFA.

Staying at Pine Needles? Call 800-747-7272 to make your reservations and request the NCHCFA Putter Club, Cabana Club, or Recharge Club. NCHCFA cannot book reservations on your behalf.

Not Staying at Pine Needles? You will pay your green fees on-site.(Required.)

Putter Club (Golf + Lodging): All events including lunch, reception, dinner, golf tournament, cart rental, & Wed breakfast // Per Person Per Night: Single $365; Double $295

Recharge Club (Spa + Lodging): Lunch, (1) 50-minute spa treatment with gratuity included at The Spa at Pinehurst, reception, dinner, & Wed breakfast // Per Person Per Night: Single $410; Double $345

Driver Club (Golf Only): Lunch & Golf Tournament only: $185

Cabana Club (Lodging Only): Reception, dinner, & Wed breakfast // Per Person Per Night: Single $225; Double $170

*10.I have called Pine Needles to make my reservation for the Putter Club, Recharge Club, or Cabana Club OR I will pay my green fees to the Mid Pines Golf course for the Driver Club.(Required.)

Yes - I have made my reservations (which includes my golf or spa choice) through Pine Needles.

I will pay my green fees on-site for the NCHCFA Driver Club package (only if not staying at Pine Needles).

11.Golf Participants, please list your golf handicap.

12.Golf Team/Partner Preference - NCHCFA will honor requested pairings whenever possible

13.Spa Participant: Select one 50-minute Spa Treatment (NCHCFA will schedule on your behalf during the golf tournament).

Pinehurst Facial - 50 Minutes: Specially designed for sensitive skin. This facial calms the skin, reduces redness, inflammation, and visible capillaries. Using vitamins it treats irritated and inflamed skin. Enjoy an even, calm and clear complexion.

Seasonal Facial - 50 Minutes: Celebrate a fresh new you with Pinehurst's Seasonal Facial. With results-oriented ingredients such as firming peptides each product is made with up to 99% natural and naturally- derived ingredients and is free of parabens, sulfates and mineral oil

*14.Photography / Videography Agreement: By entering the event premises, you consent to interview(s), photography, audio recording, video recording and its/their release, publication, exhibition, or reproduction to be used for promotional purposes, advertising, inclusion on websites, social media, or any other purpose by NCHCFA. Images, photos and/or videos may be used to highlight and/or promote similar NCHCFA events in the future. You release NCHCFA, its officers and employees, and each and all persons involved from any liability connected with the taking, recording, digitizing, or publication and use of interviews, photographs, video and/or sound recordings. You waive all rights you may have to any claims for payment or royalties in connection with any use, exhibition, streaming, or other publication of these materials.(Required.)

I agree.