Chris Phillips Goalkeeper Coaching Course Application Form

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Course:                                                                      Cost:

Venue:

Course Date:

Name:

Address:

Post Code:

Telephone:

Emergency Telephone:

Age:                                                               Date of Birth:

Gender:

Email:

I understand that Chris Phillips Goalkeeper Coaching cannot be held responsible for any personal injury or loss whilst attending the  course.

Course staff will occasionally take photographs and video footage for publicity purposes.  If you do not give permission for Chris Phillips Goalkeeper Coaching to use the pictures and video footage please tick the box.

Signature:

Signature of Parent / Guardian (if under 18 years old):

Have you any medical Conditions ? Yes / No

If Yes please specify:

Cheques

All cheques are Non – refundable

Please make cheques payable to:

Chris Phillips Goalkeeper Coaching Ltd

11 Canal Street

Ilkeston

Derbyshire

DE7 8GR