Transcript Document

SHROPSHIRE FOOTBALL ASSOCIATION
1ST4SPORT QUALIFICATIONS/THE FA
COURSE APPLICATION
Level 1 1st4sport Award in Coaching Football Qualification
JUNE FEMALE ONLY
Thursday 4th
Sunday 7th
Monday 8th
Thursday 11th
Sunday 14th
SHREWSBURY SPORTS VILLAGE
6.00pm – 10.00pm - Course Introduction / Theory
9.00am – 5.00pm – Coaching Theory / Practical
6.30pm – 9.30pm – Safeguarding Children Workshop
6.00pm – 10.00pm – Portfolio sign off / Emergency Aid
9.00am – 5.00pm – Assessment / Learner Support
Name of Attendee: _________________________________
Title______
Address: _______________________________________________________________
_______________________________________________________________________
_____________________________________Post Code_________________________
Gender Male/Female FAN (if known): _____________________
Date of Birth______________________________
Tel No: (Home) ___________________________Tel No: (Day)____________________
Emergency No:___________________________________________ (Wife, Partner etc)
Club/Organisation________________________________________________________
E-MAIL__________________________________________________________________
Please note unless stated ALL confirmation will be sent via email. If you do not have
internet access please advise and your information will be sent in the post.
Signature of Attendee ______________________________________________________
Methods of Payment:
• To book on line www.shropshirefa.com
Submission of this booking form will constitute an invoice for course costs if
payment is not received prior to start of course.
*Name of Payer / Club / Organisation_________________________________________
Cheque / Invoice (please circle) Amount £_____________ (per person)
Invoice Address:_________________________________________________________
________________________________________________________________________
_____________________________________Post Code__________________________
Signature of Payer _______________________________________________________
If you wish to pay by credit/debit card, complete the information below and either
post the form to the address below or telephone the SFA on 01743 362769.
This is for payment only.
Cardholder Name:……………………………………………………
Card Number (16 digits) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Start Date: _ _ / _ _
End Date: _ _ / _ _
Post Code ……………………
3 Digit Security Number: _ _ _
Ethnicity – I would describe my ethnic origin as:
Disability – Do you consider yourself to have a disability?
Yes / No / Prefer not to say
If Yes, what is the nature of your disability? (Please circle)
Hearing
Learning
Multiple
Visual
Mobility
Physical
Other
Prefer not to say
Please tick this box if you do not want to receive information from Shropshire FA
Please state any condition(s) requiring medication e.g. Asthma_______________
Please tick if you have an FA first aid qualification____________
Please tick if you have a ‘FA safeguarding children’ certificate______________(Proof will be required)
I understand that the course I am applying for will require me to participate as a coach and player and I
confirm that I am physically prepared to participate YES/ NO
I accept that Shropshire Football Association cannot be held responsible for any loss or injury I may sustain
whilst taking part in this course.
Signed………………………………..
Date……………………………………
Rules and Conditions:
•Cancellations must be received no later than 48hrs before the start of the course by either letter or
email or the full charge will be payable.
•Refunds will not be issued after this deadline. All courses are subject to participants numbers.
•In the event of a course being cancelled you will be contacted no later than 48hrs before the course
is due to run. In the event of this full refunds will be given.
Data Protection
The information provided by the applicant will be used solely for the purposes of the Shropshire
Football Association.
Please complete this form and return with your cheque/invoice address to:
Football Development Department
Shropshire Football Association,
Oteley Road, Shrewsbury. SY26ST
Email: [email protected]
Cheques payable to “Shropshire Football Association’
Please write ‘Coach Ed’ on back of cheque.
CLOSING DATE: 1 WEEK PRIOR TO START OF COURSE