PORT LINCOLN 'KICKSTART' HOLIDAY CLINIC
Registration form
Personal Information
Parent/Guardian
Name
*
First Name
Last Name
Email
*
example@example.com
Contact Number
*
Please enter a valid phone number.
Format: 0000 000 000.
RAA Member Number (if applicable)
Player Information
Age Group
*
5-9 Years Old - Wednesday, 22nd April (9.30am - 12.30pm)
Player Details
*
First Name
Last Name
DOB
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
$55.00 AUD
$
55.00
AUD
Quantity
1
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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
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Expiration Month
Expiration Year
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Expiration Year
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