Toowoomba Basketball Strength and Conditioning Term 4

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Client 1 Details Parent/Guardian Details
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Client First Name: Mother's Name:
Client Last Name: Mother's Email Address:
Date of Birth: Mother's Mobile/Cell:
Gender: Male Female Father's Name:
Email Address: Father's Email Address:
Confirm Email Address: Father's Mobile/Cell:
Home Phone: Do you have any injury concerns?
Mobile/Cell:
Address 1:
Address 2: Do you have any medical conditions?
Suburb/Town:
State/Prov:
Zip/Postcode:

Training Dates: From 03-Oct-2017 To 08-Dec-2017

Training Days & Times:
Once a time slot is full you will be asked to make another choice.

        Tue Fri
5:00 pm U/14 & U/12 55-57 Kitchener Street, Toowoomba $125
5:30 pm U/18 & U/16 55-57 Kitchener Street, Toowoomba $125

DISCLAIMER:
I hereby agree to assume all risks and responsibilities surrounding my (or my child's) participation in the program under the instruction of Vision Exercise Physiology coaches. I understand that similar to all sporting activities, there is a risk of damage to personal property, injury or death which may result from causes beyond the control of, and without fault or negligence of Vision Exercise Physiology, its officers, agents, or employees, during the period of my (or my child's) participation. I understand completely the above agreement and agree to be bound thereby. By registering on our site you agree that we may send you email related to our facilities and programs. We will not provide your details to any other company.

I agree (Parent/Guardian):
Date: 24-Oct-2017
There are no refunds for any enrolments into Vision Exercise Physiology related programs. When you sign/tick confirmation for this enrolment you are acknowledging that you know this as a fact and have accepted it as a condition.
Payment Method:
Cost: $125.00
Total Cost: $125.00
Credit Card: Credit Card (Ezidebit)
  
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