Toowoomba Basketball Strength and Conditioning Term 3

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Client 1 Details Parent/Guardian Details
Username Password
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If you do not have a username and password, one will be created for you when you submit this form.
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 10-Jul-2017 To 16-Sep-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 $50
5:30 pm U/18 & U/16 55-57 Kitchener Street, Toowoomba $50

DISCLAIMER:
Prepayment required via Credit Card or PayPal.

I agree (Parent/Guardian):
Date: 22-Aug-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: $50.00
Total Cost: $50.00
Credit Card: PayPal
  
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