Microsoft word - cdsfa striker reg form 2013 - fill form.docx

CDSFA STRIKER SCHOOL PROGRAM
STRIKER SCHOOL MEDICAL & REGISTRATION FORM
Please complete this Registration form and send along with cheque made payable to Canterbury & District Soccer Football Association c/o CDSFA at PO Box 402 Croydon Pk, NSW 2133 or by faxing 9716 8559. Registration closes on Monday 30th September, 2012. This course is for 2013 FFA registered players ONLY
Please note that faxed registrations will not be confirmed until payment is received.
(EFTPOS and Credit Card facilities are available at CDSFA Office at 42 Arthur Street, Ashfield)
(Eastern end of Pratten Park Bowling Club) or via phone: (02) 9716-8558
Or on page 2 of this form

Tick Session time & Day: Monday (8/10-3/12) 5:10-6:10pm
I give permission for my child to attend the CDSFA Striker School Program for the days, respective dates & times ticked above. I authorise the coaches of the Program to act for me, accordingly to their best judgement, in any emergency requiring medical attention and to call on the services of an ambulance if needed. I agree to accept responsibility for any costs involved. By signing I hereby acknowledge that my child is registered with the NSW Football Association. ____________________________ Is your child taking any DRUG or MEDICATION or under any type of TREATMENT or have any CONDITION which may prevent full involvement in the programme? If yes please give details or attach note. (e.g. Ventolin for Asthma. N.B. Asthmatics should bring a spare puffer). Has your child had, or been in contact with, any infectious diseases (including the normal childhood diseases) in the past three months? If YES please give details or attach note. Does your child have any special dietary/food requirement? If so please give details (This does not
include foods which are disliked):
1 Striker School Registration Form| CDSFA & Trinity Grammar School P R IM A R Y C O N TA C T P E R S O N – parent of guardian contact details

Name:

S E C O N D A R Y C O N TA C T P E R S O N – parent of guardian contact details

Name:

Credit Card and EFTPOS facility available:
Full Name of Cardholder (as it appears on card): (last 3 digits on back of card - if applicable) Date: / Signature of Cardholder:________________________________
Please Note: If paying via credit card then this deduction will not be made until approximately Friday, 4th
October 2013. Processing of payment is delayed due to ensuring that the program is filled and won’t be
cancelled due to lack of interest. If minimum numbers are achieved prior to 4th October, then payment will be
processed immediately and receipts issued and posted (please ensure an address is supplied for receipts to
be forwarded).
If your card expires prior to the process of fees for the course – please ensure you call Jennifer at CDSFA on
(02) 9716-8558 to supply new card details. Registration will not be finalized/counted without full payment of
fees.
2 Striker School Registration Form| CDSFA & Trinity Grammar School

Source: http://www.roselandsfc.com.au/Docs/CDSFA%20Striker%20Reg%20Form%202013%20-%20Fill%20Form.pdf