WHYALLA 'KICKSTART' HOLIDAY CLINIC
Registration form
Personal Information
Parent/Guardian
Parent/Guardians Name
*
First Name
Last Name
Email
*
example@example.com
Phone
*
Please enter a valid phone number.
Player Information
Player details
*
Age Group
*
5-8 yrs old, Tuesday, 7th October (9.30am-1.00pm)
9-14 yrs old, Wednesday, 8th October (9.30am-1.00pm)
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
*
my Products
*
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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: