KICKSTART Single Day School Holiday Clinic
Registration form
Personal Information
Person Responsible for child
Name
*
First Name
Last Name
Email
*
example@example.com
Age Group
*
5-8 Year Old (single day)
Please select day:
Single day - 3rd Oct (9:30am - 1:00pm)
Single Day - 3rd Oct (1:00pm - 4:30pm)
Single day - 7th Oct (9:30am - 1:00pm)
Single Day - 7th Oct (1:00pm - 4:30pm)
Single Day Girls ONLY - 7th Oct (9:30am - 1:00pm)
Player details
*
Has any player been identified as living with a disability?
*
Yes
No
Please specify
*
Where did you hear about the program?
*
Please Select
Social media
Email
Word of mouth
Radio
Tv adverts
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My Products
*
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Single Day 3rd Oct (5 - 8 Years Old)
one day only
$
55.00
AUD
Quantity
1
2
3
4
5
6
7
8
9
10
Single Day 7th Oct (5-8 Years Old)
$
55.00
AUD
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit registration
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