2022 Speed Clinic Form Application Form

Speed Clinic

Register to learn how to improve your running technique, speed & strength! Age: 12-16 | 4th & 6th July from 10am -12pm (second week of the school holidays)
Athlete Information
Athlete's Name

First Name Last Name
Birth Date

Month Day Year
Athlete Email
example@example.com
Gender
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Player Profile
Sport

Coach/s
Club Name Number of years playing
What do you want to achieve from the two day speed clinic?
Parent/Guardian Information
Name

First Name Last Name
Mobile Number
Relationship
Home Number
E-mail
example@example.com
Emergency Information (only fill in if different from the above details)
Emergency Contact's Name

First Name Last Name
Relationship
Phone Number
E-mail
example@example.com
Medical Information
Does the athlete have any current or recurring injuries, allergies, chronic illness, or medical conditions? If yes, please describe.
Application close strictly C.O.B 25th June. Please ensure you keep an eye on your emails for important information being sent out such as acceptance, payment details and relevant information.

An invoice will be sent via email prior to close of applications and is expected to be paid to confirm involvement in the clinic.

For further information please contact Annaleise Stoyko, Programs Manager:

0412 756 524 or programs@goldsport.com.au
File Upload

If you would like to upload any further information please do so here.
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