Application form Please complete in BLOCK CAPITALS. Course name: ................................................................. Course code: .................................................................. Please tick Block 1, Block 2 or both Block 1 Block 2 Both Child’s details First name(s):................................................................... Surname:......................................................................... Date of birth:................................................................... Gender: Male Female Which school does the child attend?............................................................................................................................ Does the child suffer from any illness or learning or physical disabilities which should be brought to our attention? YES / NO If YES, please give brief details on a separate sheet and attach to this form. Special dietary requirements (if any): ........................................................................................................................... Parent’s/guardian’s details First name(s):................................................................... Surname: ........................................................................ Address: ...................................................................................................................................................................... ....................................................................................... Post code:....................................................................... Home tel (inc STD):.......................................................... Work tel: . ....................................................................... Mobile tel: ...................................................................... Emergency tel: ............................................................... E-mail address*............................................................................................................................................................. *We only confirm places via email, so you will need to supply us with a valid email address should you wish to receive such confirmation. As of 31 October 2014, we will use data held by us for the following purposes only: We may process the personal data submitted by you (as defined by the Data Protection Act 1998) for the purposes of (i) the administration of files and records, (ii) the marketing and promotion of our similar products and services (and disclosure to carefully selected third parties so that they may undertake this marketing on our behalf), (iii) disclosure to Norwich City Football Club Plc (or carefully selected third parties acting on its behalf) to enable it to contact you in relation to its products and services, (iv) customer services, (v) monitoring and evaluation purposes and/or for (vi) fulfilling our obligations to you. More information can be found at www.communitysportsfoundation.org.uk Authorisation details Authorised to collect my child (other than myself): ...................................................................................................... Relationship to child: ................................................................................................................................................... Declaration by parent or guardian: I wish for my son/daughter to be accepted on the above course, and I agree to the terms and conditions above and confirm that any medical condition which may affect my child’s participation on the course has been fully disclosed. Health and safety: I give permission for CSF / relevant partners to administer first aid to myself/my child if necessary, and to transport me/him/her between relevant venues if required, or to hospital should an emergency arise. Photography: I give permission for CSF / relevant partners to take and use photographs of myself / my child for future publications and publicity. Signature: ...................................................................................................... Name: ........................................................................................................... Date: ............................................................................................................. Office use only: Paid: Data: Conf: Payment details I enclose a cheque / postal order payable to “Community Sports Foundation” for £ ..................................... or I wish to pay three monthly instalments of £............................ (first payment due within seven days of booking) Please write your child’s name and booking code on the back of the cheque before returning Please charge my credit / debit card for £........................ Cardholder’s name ........................................................ Visa / MasterCard / Switch number: ......................../........................./........................./....................... Valid From Date: ............/............ Expiry Date: ............/............ Issue No. (if applicable): ............ Security Code (last three digits on card signature strip): ............ Full terms and conditions can be found on the website at www.communitysportsfoundation.org.uk Norwich City Community Sports Foundation Norwich City FC, Carrow Road, Norwich, NR1 1JE www.communitysportsfoundation.org.uk / 01603 761122 / Registered charity number: 1088239 Mini Kickers 2015 A fun introduction to weekly football for four to seven year olds Norwich Cromer www.communitysportsfoundation.org.uk Norwich - Carrow Park, Norwich City Football Club Tuesdays Wednesdays Saturdays 4pm - 5pm 4pm - 5pm 9am - 10am 10am - 11am 11am - 12pm (ages 4-6) (ages 4-6) (ages 4) (ages 5) (ages 6-7) MK 1 MK 2 MK 5 MK 6 MK 7 Cromer - Cromer Sports Centre, Norwich Road Wednesdays Mini Kickers is a fun introduction to football for four to seven year olds that provides a mix of coaching, skill tests and mini matches. With an emphasis on fun, we aim to develop a child’s footballing ability, balance, coordination and social skills. Our centres provide fantastic, welcoming environments to excite and encourage children, as they take their first step on the football pathway. Book Now Online discounted price 4pm - 5pm (ages 4-6) MK 3 Block 1 Block 2 Tuesdays, Wednesdays & Saturdays Tuesdays, Wednesdays & Saturdays February 3rd - July 18th September 8th - November 28th 24 week course cost 12 week course cost Book online for exclusive discount £84 £75 You save £9! Book online for exclusive discount £48 £45 You save £3! 01603 761122 Direct Debit & payment plans Post Spread the cost payment plans and payment via Direct Debit are also available. For more information, call the office on 01603 761122 or visit the Mini Kickers page on the website. Please note, you can only book via these options if booking before the course start date. An admin fee will apply. Visit the CSF Office Please note: £1.50 booking fee for phone bookings Book online now at www.communitysportsfoundation.org.uk @NorwichCityCSF facebook.com/communitysportsfoundation 01603 761122