PORT LINCOLN 'KICKSTART' HOLIDAY CLINIC
Registration form
Personal Information
Parent/Guardian
Name
*
First Name
Last Name
Email
*
example@example.com
Age Group
*
5-8 Year Old - Thursday, 8th Jan (9.30am - 1.00pm)
Player details
*
Do you give consent for the above player to have their photo taken across the KICKSTART 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
$
55.00
AUD
Quantity
1
2
3
4
Item subtotal:
$0.00 AUD
$
0.00
AUD
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
Submit registration
Should be Empty: