Football Xtra Aug 2019 with Coleraine Baptist Church
Thanks for your interest in registering for Football Xtra, Mon 12th - Thu 16th August 6.30-8.30pm.

We're planning a great programme of football drills and skills coaching, as well as matches, ending with the ever-popular World Cup tournament.

All of this will take place at the Rugby Avenue playing fields, Coleraine. It's open to children aged 6-12. Please bring shin pads and football boots.

There's no charge for participation.

See you there!

Email address *
Child's Details
Full name of child *
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Date of birth *
dd/mm/yyyy
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Gender *
Age *
Details of any medical conditions or allergies (e.g. Asthma, diabetes, epilepsy) and any medication *
If none, please write 'none'.
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Any other special needs, requirements or directions that would be helpful for leaders to know about *
If none, please write 'none'.
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Address *
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Emergency Contact Details
Please supply names and phone numbers of at least two people we can contact in an emergency. Please include a parent or guardian first. *
Please supply numbers, including area codes, where emergency contacts can be reached during the running times of the club.
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Name and phone number of child's GP *
Your answer
Small Print about Safety
By giving my name below as the registering parent or guardian, I agree to the following terms.

1) I will inform the leaders of any changes to my child's health, medication needs and any changes to the address or phone numbers given. Email colerainebaptist@yahoo.co.uk or call Eric Chambers on 07901853703.

2) In the event of illness or accident, having parental responsibility for the above named child, I give permission for first aid to be administered where considered necessary by a trained first aider, if available, or by a suitably qualified medical practitioner.

3) If I cannot be contacted and my child should require emergency hospital treatment, I authorise an adult leader to sign on my behalf any written form of consent required by the hospital. However, I understand that every effort will be made to contact me as soon as possible.

4) During the event photography/video filming may be taken for general purposes, permission for which is needed. By giving my name below, I give my permission.

Name of parent/guardian *
Please type your name again in lieu of a signature.
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Date of registration *
dd/mm/yy
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A copy of your responses will be emailed to the address you provided.
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