enrol online at www.roaractive.com.au or return completed forms to: Fax: 07 3009 0516 Email: [email protected] Post: Brisbane Roar FC, Locked Bag 10 Kelvin Grove BC 4059 The Roar Holiday Clinic includes: 2 Days of Football Fun with our Roar Coaches Registration for: Payment details: Pauls Supporters Pack & T Shirt iplay Sports Indoor Venue, 17 Flinders Pde, North Lakes Thursday 18th December & Friday 19th December 2014 Skills, Drills and Fun Indoor Games for all levels To register go to www.roaractive.com.au Holiday Programs Venue: NORTH LAKES - iplay sports Indoor Venue Dates: Thursday 18th Dec & Friday 19th Dec 2014 Times: 9 00AM - 12 00PM DAILY Grades: AGES 5 - 12 YEARS Your child’s details Mastercard Visa Card number: Expiry date: Full name: Date of birth: Credit card Age: School grade: Cheque/money order Please make payable to Brisbane Roar FC and attach to this registration form. Home phone: Cheque No: The Roar Holiday Clinic is a unique way to learn from the champions and get active whilst having fun! Mobile: Amount: Email: Parent/guardian disclaimer We offer highly skilled coaches and a structured program that caters to a variety of age groups and skill levels. Get in early to avoid missing out as numbers are limited. Address: Cost: $75 PER CHILD Don't forget to bring a snack, waterbottle, sunscreen, a hat and running shoes! Postcode: Medical conditions: For enquiries please contact Rozanne Burley on 0448 136 986 or [email protected] I certify that my child enrolled hereon is in excellent health and may participate in strenuous physical activities including soccer. I agree to defend and hold Brisbane Roar FC, its servants, agents and/or employees and contractors harmless from any and all claims for injuries that may be sustained by my child during his or her participation in the camp. Permission is hereby granted to Brisbane Roar FC to use pictures of the participants in any promotional materials. Permission is granted for my child to receive emergency medical treatment, if needed, and I certify that there are no limits to my child’s participation except as stated in writing and included with this application. Acceptance Parent/guardian name: Emergency contact details Name: Number: CCV: Signature: Date: