This form should be completed by the parent/guardian with parental responsibility before
your child can participate in the Nutty Krust Easter Holiday Camp. Use one form per child. Photocopy this form if booking more than one child.
Please print clearly.
I agree to my child (Name):____________________________________ participating in the Irish FA Easter Holiday Camp at (Venue):______________________________________________ Date:________________________
Personal Details
Name of Parent/Guardian:_______________________________ Home Tel:___________________________
Home Address:______________________________________________________________________________
Post Code:____________________ Child’s Date of Birth:____________________ Age:__________________
IRISH FA Nutty krust
EASTER HOLIDAY CAMPS
for boys and girls aged 5-13
8th, 9th, 10th April 2015
Email (please provide):_____________________________________________________
Emergency Contact Details
Please provide the name and telephone numbers of two people who we may contact in case of an emergency.
Contact 1
Contact 1
Name:
Name:
Address:
Address:
Home Tel:
Home Tel:
Mobile:
Mobile:
Endorsement by Parent/Guardian [delete as appropriate]
In the event of illness or accident, I give permission for first aid to be administered where considered necessary by a
nominated First Aider, or suitably qualified medical practitioner. In case of emergency, I understand that staff will do
everything possible to contact the parent/guardian so that they can make the appropriate medical decisions for the
child. In extreme circumstances where medical treatment is required without delay, I authorise the leader in charge to
give consent for any medical treatment on my/our behalf:
AGREE/DISAGREE
I give my consent for my child to be photographed/videoed for the use of publicity only, which may include use on
the Irwin’s and Irish FA websites, in line with the Irish FA’s policy:
AGREE/DISAGREE
Please give details of any relevant medical history of child including allergies: (If more space is required, please include on a separate sheet).
___________________________________________________________________________________________
I confirm that all details are correct to the best of my knowledge. I give permission for my child to attend the Irish FA
Easter Holiday Camp.
Signed by Parent/Guardian:_______________________________________ Date:_______________________
Please return application form and payment ASAP to:
Easter Holiday Camps, Irish Football Association, Unit B, Adelaide Business Centre, 4 Apollo Road, Belfast BT12 6HP.
All Cheques made payable to ‘Irish Football Association’ (£25 per child)
For more information call 02890 684710
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Book online at
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www.irishfaholidaycamps.com
List of Camps
Regional Grassroots Development Officer
Mobile
E-mail address
Ciaran Donaghy
Cookstown, Dungannon & Magherafelt
07894 614304
[email protected]
Craig Bowers
Belfast South & East
07894 614303
[email protected]
Sean-Paul Murray
Belfast North & West
07802 327540
[email protected]
Joe Doherty
Causeway Coast & Glens
Ken Duncan
Armagh, Banbridge & Craigavon
07802 327593
07802 327553
[email protected]
[email protected]
Kevin Doherty
Derry & Strabane
07802 327592
[email protected]
Kyle Spiers
North Down & Ards
07966 373384
[email protected]
Phil Melville
Lisburn City & Castlereagh
07967 459738
[email protected]
Seamus Heath
Newry, Mourne & Down
07515 062882
[email protected]
Stephen Erskine
Fermanagh & Omagh
07894 614310
[email protected]
Steven Livingstone
Antrim & Newtonabbey
07894 614306
[email protected]
Wes Gregg
Mid & East Antrim
07802 327594
[email protected]
Book online at www.irishfaholidaycamps.com
For further information on courses please contact the Grassroots
Development Officers at the e-mails / phone numbers listed above.
Venue
Dates
Times
Mid Ulster Sports Arena, Cookstown
April 8th, 9th ,10th
10am - 1pm
Moyola Park F.C., Castledawson
April 8th, 9th ,10th
10am - 1pm
Cherryvale Playing Fields
April 8th, 9th ,10th
10.30am - 1.30pm
Orangefield Park
April 8th, 9th ,10th
10.30am - 1.30pm
Ballysillan Leisure Centre
April 8th, 9th ,10th
10am - 1pm
Colin Park, Blacks Road
April 8th, 9th ,10th
10am - 1pm
Dunclarave Playing Fields, Bushmills
April 8th, 9th ,10th
10.30am - 1.30pm
St Pauls’ College, Kilrea
April 8th, 9th ,10th
10.30am - 1.30pm
Scroggy Road, 3G, Limavady
April 8th, 9th ,10th
10.30am - 1.30pm
Craigavon City, Drumgor
April 8th, 9th ,10th
10am - 1pm
Loughgall Country Park
April 8th, 9th ,10th
10am - 1pm
Ebrington Primary School,
Lapwing Way, L’Derry
April 8th, 9th ,10th
10am - 1pm
Castlederg High School
April 8th, 9th ,10th
10am - 1pm
Bangor Aurora 3G
April 8th, 9th ,10th
10am - 1pm
Holywood Spafield 3G
April 8th, 9th ,10th
10am - 1pm
Laurelhill Community Centre, Lisburn
April 8th, 9th ,10th
10am - 1pm
Loughmoss Centre, Carryduff
April 8th, 9th ,10th
10am - 1pm
Kilmore Road Playing Fields, Crossgar
April 8th, 9th ,10th
10am - 1pm
Kilkeel Leisure Centre
April 8th, 9th ,10th
10am - 1pm
Lakeland Forum, Enniskillen
April 8th, 9th ,10th
10am - 1pm
Omagh Leisure Centre
April 8th, 9th ,10th
10am - 1pm
Crumlin Community Centre, Antrim 3G
April 8th, 9th ,10th
10am - 1pm
Valley LC, Newtonabbey
April 8th, 9th ,10th
10am - 1pm
Ballymena Showgrounds
April 8th, 9th ,10th
10am - 1pm
Sandy Bay, Larne
April 8th, 9th ,10th
10am - 1pm
Price: Online PRICE
1 Child
2 Children
3 Children
£20.00
£30.00
£40.00