PAYMENT EFT Payment Glory Football Club’s Community Department BSB: 036-011 – Account: 422860 aim to provide children of all abilities a dynamic, Reference: Include program code SS and child’s surname challenging and fun experience within a professional training environment. Date of payment:______For details and general information about the Cheque Community Department please: Payable to Perth Glory Football Club (PO Box 1366 West Leederville WA 6901) visit www.perthglory.com.au Credit Card or email [email protected] Please charge to my credit card: Visa MasterCard

Card number: ______/ ______/______/______

Expiry date: ___ /___ CVV number: ______

Cardholder’s name:______

Signature: ______

TOTAL AMOUNT:______*Refunds available upon presentation of Doctors medical certificate You agree not to bring any claim or proceeding against Perth Glory FC, their sponsors, their employees, and volunteers of the event for any damage, loss, injury or liability you or your Child may suffer from participating in the event, within reason.

PHOTOS (PLEASE READ CAREFULLY) Please tick the box if you DO NOT authorise the event staff to take pictures/videos of your Child. You acknowledge that the event organiser’s may use pictures/video of your Child in publicity and advertising material (children’s names are not used in conjunction with images) and that copyright and all associated rights in these pictures/videos is owned by Perth Glory FC. Please tick the box if you do not want to be contacted by Perth Glory FC with further information on the club’s activities. For Soccer Schools Terms & Conditions please see perthglory.com.au

PARENT/GUARDIAN SIGNATURE: I,______(print name) am the parent/ guardian of the named Child. I have read this document and understand its contents, including the exclusion of liability and assumptions of risk, and consent to my Child attending/participating in the Event. Signature:______PERTH GLORY WOMEN AND MATILDA Date: _____/_____/ 2015 CHECK OUT THE VENUE DETAILS AND TIMES REGISTER NOW SUBIACO AFC’S LAKE JUALBUP PARENT GUARDIAN DETAILS SOCCER SCHOOLS! 9am to 3pm - Tuesday 29th and Wednesday 30th of September Full Name:______Train and play with the Glory at the A-League’s best clinics SORRENTO FC’S MARRI PARK Address:______this School Holidays. 9am to 3pm - Thursday 1st and Friday 2nd of October Suburb:______Postcode:______• Play BAYSWATER CITY’S FRANK DRAGO RESERVE Email Address:______• Improve ONLY 9am to 3pm - Monday 5th and Tuesday 6th of October Home No:______• Enjoy $ Soccer Schools cater for ages 4 – 13yrs old. 160 MELVILLE CITY’S LEN SHEARER RESERVE Mobile No:______9am to 3pm - Monday 5th and Tuesday the 6th of October How did you hear about the Soccer Schools?______PROGRAM DETAILS CARRAMAR FC’S HOUGHTON PARK ______9am to 3pm - Thursday 8th and Friday the 9th of October CHILD 1 For a total investment of $160 Full Name:______each participant will receive: GIRLS ONLY SOCCER SCHOOLS Date Of Birth:______• Professional Coaching SPECIAL PRICE - $ 50 Gender: Male Female • Soccer Schools Shirt UWA/NEDLANDS CHARLES COURT RESERVE 9am to 12pm - Tuesday 6th October Primary School:______• PGFC Backsack Including special Matilda player appearance Football Club:______• Child’s General Admission Medical Conditions (if any): Attach details • Ticket MEET THE COACHES • PGFC Waterbottle Emergency Contact:______• Perth Glory Team Poster CALLUM SALMON Soccer School Location:______Community and Development Manager CHILD 2 • PGFC U18 Head Coach Full Name:______PARTICIPATION • UEFA B License REQUIREMENTS Date Of Birth:______MICHAEL GARCIA Gender: Male Female • Appropriate football attire Community and Development Officer Primary School:______• 2 x Waterbottles • FFA C License Coach Football Club:______• Sunscreen • Former Perth Glory player Medical Conditions (if any): Attach details • Packed lunch Emergency Contact:______STEVEN MCGARRY Community and Development Officer Soccer School Location:______CHOOSE LOCATION DISCOUNTS AVAILABLE: • Most Glorious Player 2012/13 Subiaco AFC’s Lake Jualbup Tue 29th and Wed 30th Sep Loyalty: Attendees from July Soccer Schools $144 • Golden Boot 2013/14 Sorrento FC’s Marri Park Thu 1st and Fri 2nd Oct Sibling: First child $160 and additional children $120 each Bayswater City’s Frank Drago Reserve Mon 5th and Tue 6th Oct STEPHEN PURTON Melville City’s Len Shearer Reserve Mon 5th and Tue 6th Oct Community and Development Officer Carramar FC’s Houghton Park Thu 8th and Fri 9th Oct To register online please visit www.perthglory.com.au GIRLS ONLY SOCCER SCHOOLS: & for further information email [email protected] • FA Level 2 Coach If you have any further questions please email • NPL State League Coach UWA/Nedlands Charles Court Reserve Tue 6th Oct or call the office on9492 6000