BFCA Course Registration Form

Participant's Name*

First NameMiddle NameLast Name

Birth Date*

MonthDayYear

Gender*

Please Select

Address

Street Address

Street Address Line 2

Parish

Postal / Zip Code

E-mail*

example@example.com

Mobile Number

Area CodePhone Number

Phone Number*

Area CodePhone Number

Work Number

Area CodePhone Number

Current Club or School Affiliation

What age level are you currently coaching?

U7, U9, U11, U13, U15, U17, SENIOR

Have you obtained any previous coaching licenses? If yes please list course details / date awarded

Example: UEFA B - 2016 Scottish FA

Have you previously registered for a BFCA course?*

No? Yes? -Course level and date

Which Course are you registering for?*

Select from drop down menu

Additional Comments

INSURANCE INFORMATION

Is the participant covered by insurance?*

Yes I have insurancePresently I am not insured

Name of Insurance Company

Policy Issued to?

Group number

Policy number

Do you have any pre-existing conditions that would prevent you from participating fully?*

Yes, I have a pre-existing conditionNo existing conditions

Please list pre-existing conditions

Do you have any allergies to medicine, food or otherwise? If yes please list below

IN CASE OF EMERGENCY

EMERGENCY CONTACT NAME*

EMERGENCY CONTACT NUMBER*

INJURY AND LIABILITY WAIVER

I certify that the above information is true and correct to the best of my knowledge. I understand that football is a contact sport, and that there are inherent risks of injury associated with playing and participating in this course. I hereby hold harmless the Bermuda Football Coaches Association, its instructors and staff, and the facility operators for any injury sustained while participating in this course. I authorize the Bermuda Football Coaches Association and its representatives to provide basic first aid in the event of a minor injury and also authorize them to seek urgent medical care from a doctor or physician if deemed necessary and required. I will be responsible for any costs incurred for related medical and emergency services in the event it is required. I also grant the Bermuda Football Coaches Association the right to use pictures and video captured from this course that may contain my likeness for future use in promotional, marketing and educational materials.

Select below to indicate you agree to the waiver and terms above*

I agree and accept to be registered for the course selected

PAYMENT DETAILS

Registration Costs - $500

Payments can be made by cheque or cash or directly to our account at the HSBC, Acc. No. 011‐113669‐001. Please include your name on the payment.

Cheque or cash payment can be hand delivered in a sealed envelope to the offices of the Bermuda Football Association for collection by the BFCA. Please label the envelope Attention: BFCA C License - Participant's Name.

Payment will be made via:

How will you pay for the course?

C License Registration Form