Single Day School Holiday Clinic
Registration form
Personal Information
Person Responsible for child
Name
*
First Name
Last Name
Email
*
example@example.com
Age Group
*
5-9 Year Old (single day)
Please select day:
Single Day - 18th April (9:30am - 1:00pm)
Single Day - 19th April (9:30am-1:00pm)
Single day - 24th April (9:30am - 1:00pm)
Player details
*
Has any player been identified as living with a disability?
*
Yes
No
Please specify
*
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Single Day 18th April (5 - 9 Years Old ONLY)
one day only
$
50.00
AUD
Quantity
1
2
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5
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9
10
Single Day 19th April (5 - 9 Years Old ONLY)
Single Day only
$
50.00
AUD
Quantity
1
2
3
4
5
6
7
8
9
10
Single Day 24th April (5 - 9 Years Old ONLY)
One day only
$
50.00
AUD
Quantity
1
2
3
4
5
6
7
8
9
10
Single Day 26th April (5 - 9 Years Old ONLY)
Single day only
$
50.00
AUD
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit registration
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