KICKSTART Single Day School Holiday Clinic - West Beach Parks Football Centre
Registration form
Personal Information
Person Responsible for the child
Name
*
First Name
Last Name
Email
*
example@example.com
Age Group
*
5-8 Year Old
Date Select
*
Oct 2nd 9:30am - 1:00pm
Oct 10th 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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My Products - TIME 9.30am to 1.30pmApril 17th
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DATE SELECTION - School Holiday Clinic
$
55.00
AUD
Quantity
Price
Oct 2nd
1
2
3
4
$
55.00
AUD
Oct 10th
1
2
3
4
$
55.00
AUD
Item subtotal:
$
0.00
AUD
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit registration
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