Registration Form - I'MPossible Football Club

I'MPossible FC Registration Form
I'MPossible FC is a Football Club especially designed for people with a disability. It will have speciaised coaching, equipment and a world class facility to cater for players of all disabilities ranging from age group 10+.

Our aim, like with the I’MPossible Program is to provide a safe and nurturing environment where a player can just come along for fun and meet new friends or build and develop their Football skills to transition to mainstream football, Para football, deaf football whatever they desire, this is the essence of I’MPossible.

The cost of each session is $48.50 and will be able to be covered through NDIS if self or plan managed.
Player Details
Player Name*

First NameLast Name
Preferred name ?*
Date of Birth*

DayMonthYear
Date
Gender*
Phone Number*
Please enter a valid phone number.Format: 0000 000 000.
Email*
example@example.com
Address*

Street Address

SuburbState

Postcode
Primary Disability? *
Details of any Behaviour Management plan or other relevant information?

NDIS or Payment Details
NDIS Number
n/a if no NDIS plan
Plan expiry date?

DayMonthYear
Date
NDIS Plan

Please attach your NDIS Plan for our reference (information is securely stored)
Cancelof
Primary goal(s) for using I'MPossible FC?
CoreCapacity - Improved Health and WellbeingCapacity - Increased Social and Community participationUnsure
How is your NDIS plan managed? *
Invoice to*
Phone Number
Please enter a valid phone number.Format: 0000 000 000.
Email*
example@example.com

Emergency Contact

Parent/Guardian or Advocate ReprSaveesentative
Primary Emergency Contact*

First NameLast Name
Emergency Number*
Please enter a valid phone number.Format: 0000 000 000.
- 2nd Emergency Contact
  
  First NameLast Name
- Emergency Number
  Please enter a valid phone number.Format: 0000 000 000.

Please type name of the person signing this document
Full name or Athlete, Parent/Guardian or Authorised Representative
I, certify and acknowledge; That I understand the potential risks involved in participating in any physical exercises or activities within the S6HP I'MPossible Program and assume the responsibility and risks. I understand that participating in an exercise program may include, but not limited to, serious bodily injury, heart attack, paralysis, stroke or even death. I consent voluntarily to participate in the S6HP I'MPossible Program, S6HP Remote Program delivered by S6HP I'MPossible Pty Ltd.

That the Parent or Guardian give permission for their Child named above to be able to participate in the online S6HP Remote Program, and at times communicating with the Coaches and Mentors within the online classroom.

S6HP I'MPossible is not responsible for the training environment the remote Athlete may choose to train, although advice can/will be given what a safe training environment should be, ultimately it is the responsibility of the parent to control the remote training environment.

That S6HP I'MPossible and any Coach of S6HP I'MPossible have advised me prior to the commencement of participation in the I'MPossible Program that participation could result in physical injury.

That I freely and knowingly assume the risk in all Programs delivered by S6HP I'MPossible Pty Ltd, and hereby waive any right, claim or cause of action against S6HP I'MPossible Pty Ltd and release them from any liability for any injury, cost, damage or expense, loss of personal property or claim whatsoever arising, which I or anyone on my behalf might incur as a direct result or indirect result of participation in the S6HP I'MPossible Program/s.

You acknowledge and consent to photographs and electronic images being taken of you during S6HP I'MPossible Program/s. You acknowledge and agree the such photographs or electronic images are owned by S6HP I'MPossible Pty Ltd and that they may be used on Social Media Platforms such as Facebook, Instagram, LinkedIn and websites for promotional or other purposes without your further consent.

That I have read the above and understand and agree with each of the foregoing points
Signature*
Date

MonthDayYear
Date
GoogleSocial MediaNDIA or LACPlan ManagerSupport CoordinatorRecommended by
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I'MPossible FC Registration Form

Player Details

NDIS or Payment Details

Emergency Contact

Health/Medical Details