KICKSTART 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 - 10th Oct (9:30am - 1:00pm)
Player details
*
Has any player been identified as living with a disability?
*
Yes
No
Please specify
*
Where did you hear about the program?
*
Please Select
Social media
Email
Word of mouth
Radio
Tv adverts
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Single Day 10th Oct (5-9 Years old)
$
55.00
AUD
Quantity
1
2
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10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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