ACADEMY APPLICATION FORM 2016. I would like my ... Parent / Guardian signature: / / 2015. COST OF ... Credit Card (Maste
ACADEMY APPLICATION FORM 2016
I would like my child to attend the 2016 Point Cook Football Club Academy.
My child’s details are as follows:
Name: Date of Birth:
/ /
Sex: M or F
Childs singlet size:
Any physical or mental conditions your child may have that our coaches/trainers should be aware of: (These will be kept private and confidential)
Parent / Guardian Name: Parent / Guardian Contact No.: Parent / Guardian Email: Parent / Guardian signature:
/ / 2015
COST OF ACADEMY IS $80 PER CHILD FOR NEW PARTICIPANTS (Pack includes Bag, Bottle, Singlet, etc) and $50 PER CHILD FOR PREVIOUS PARTICIPANTS
PAYMENT OPTIONS
•
Cheque payable to ‘Point Cook Football Club’ or Cash E mail Katie Carter below for details
•
Direct Payment to bank account: Ø Bank: Westpac Bank Ø Bank No. (BSB): 033161 Ø Account No.: 114632 Ø Reference details: Childs surname (to assist in identifying payment)
•
Credit Card (MasterCard/Visa only)
Ø Card Type:
Master Card / Visa Please circle
Ø Card Number:
Ø Expiry Date:
/ 3 number PIN on back:- _ _ _
Ø Card Holders Name:
Ø Card Holders signature: NOTE: PAYMENT MUST BE MADE PRIOR TO CHILD ATTENDING THE ACADEMY
APPLICATIONS CLOSE OCTOBER 21st E mail Academy Administrator Katie Carter at
[email protected] with any questions or call Head Coach Nigel Willingham on 0431 033 633
