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 *
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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 *
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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 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 *
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Date of registration *
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A copy of your responses will be emailed to the address you provided.
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