PORT PIRIE KICKSTART TRAINING CLINIC
Registration form
Personal Information
Parent/Guardian
Name
*
First Name
Last Name
Email
*
example@example.com
Age Group
*
5-8 Year Old (Wednesday, 1st Oct, 4.00pm - 7.30pm)
9-14 Year Old (Wednesday, 8th Oct, 4.00pm - 7.30pm)
Player details
*
Do you give consent for the above player to have their photo taken across the clinic? (will be used for social media advertising purposes)
Yes
No
Has any player been identified as living with a disability?
*
Yes
No
Please specify
*
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KICKSTART Holiday Clinic
Please buy a ticket for each registered player per date
$
55.00
AUD
Quantity
1
2
3
4
Item subtotal:
$
0.00
AUD
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit registration
Should be Empty: