KICKSTART Single Day School Holiday Clinic - Service FM Stadium
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 - 29th September (9:30am - 12:30pm)
Player details
*
Has any player been identified as living with a disability?
*
Yes
No
Please specify
*
RAA Member Number (if applicable)
Where did you hear about the program?
*
Please Select
Social media
Email
Word of mouth
Radio
Tv adverts
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KICKSTART Single Day School Holiday Clinic - Service FM Stadium
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Single Day 29th September (5 - 8 Years Old)
one day only
$55.00 AUD
$
55.00
AUD
Quantity
1
2
3
4
5
6
7
8
9
10
Single Day 2nd October (5-8 Years Old)
$55.00 AUD
$
55.00
AUD
Quantity
1
2
3
4
5
6
7
8
9
10
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
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2045
Expiration Year
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