Fast Feet Program Registration

Please complete the form below to register for a Fast Feet program.

Full Name:
Date of Birth:
Address:
Post code:
Home Phone:
Mobile:
Emergency Contact:	Name: And Number
Medical Condition:	Yes No
If YES please indicate the condition, and any medication required (if any):
Email Address:
Payment Details
Amount Paid:	$ Cash Club

	PARENT/GUARDIAN DISCLAIMER I certify that my child enrolled hereon is in excellent health and may participate in strenuous physical activities including football. I agree to defend and hold Fast Feet and its employees harmless from any and all claims for injuries that may be sustained by my child during his or her participation in the clinic Permission is hereby granted to Fast Feet to use pictures of the players in any promotional material. Permission is granted for my child to receive emergency medical treatment if needed and I certify that there are no limits to my child participation except as stated in writing and included with this application.
	I Agree
Parent / guardian name