2018 - Centre Program Enrolment Form 0412 428 195 GRASSHOPPERSOCCER.COM.AU Please send to PO BOX 212, Figtree, NSW, 2525 or EMAIL [email protected] to enrol Child’s Name: _______________________________________________________ DOB: _______________________ Parent/Guardians Name: ____________________________________________________________ Address:_______________________________ Suburb: ________________________ P/Code: __________________ Phone: __________________________________ Mobile: ______________________________________ Email: ___________________________________________ How did you hear about us? _______________________ CENTRES (Please Tick) FIGTREE (Figtree High School, Figtree) SAT AM KIAMA (Kiama High School, Kiama) SAT AM ▫ CORRIMAL (Corrimal High School, Corrimal) SUN AM ▫ LAKE ILLAWARRA (Lake Illawarra High School, Lake Illawarra) SUN AM ▫ (Please Tick) Programs run for 8 weeks except the ELITE program▫ PROGRAMS MITE-E PINT SIZE INTRO TO MICRO MICRO MICRO PLUS (2-3 yo) (4-5 yo) (5-6 yo) (6-8 yo) (8-12 yo) ELITE▫ ( 8 -12 yo - INTENSIVE▫ 6 WEEKS▫ - $100 - LOCATED AT FIGTREE▫ ONLY) ▫ ▫CLASS TIMES MITE-E PINT SIZE INTRO TO MICRO MICRO MICRO PLUS FIGTREE - SATURDAY 9.00-9.35AM 9.00-9.50AM 10.00-11.00AM 10.00-11.15AM 10.00-11.15AM KIAMA - SATURDAY 9.00-9.35AM 9.00-9.50AM 10.00-11.00AM 10.00-11.15AM 10.00-11.15AM CORRIMAL - SUNDAY 9.00-9.35AM 9.00-9.50AM 10.00-11.00AM 10.00-11.15AM 10.00-11.15AM LAKE ILLAWARRA - SUNDAY 9.00-9.35AM 9.00-9.50AM 10.00-11.00AM 10.00-11.15AM 10.00-11.15AM TERM FEE $120 $130 $135 $140 $140 PAYMENT OPTIONS: CASH, CHQ, BANK TRANSFER OR CREDIT CARD (Grasshopper Soccer has a NO REFUND Policy) Credit Card Payment (please circle) Visa Master Card Name on Credit Card ________________________________________________________________ Credit Card Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Expiry _ _ / _ _ CVV _ _ _ ADD Grasshopper Soccer Shirt, Shorts & Hat (Enrolment Special $55) Yes No Parent/Guardian Consent: I hereby authorize Grasshopper Soccer to act on my behalf should my child require medical attention, and release Grasshopper Soccer ▫ ▫ from any liability for injury incurred by my child at Grasshopper Soccer programs. ENROLMENT SPECIAL $ __________ Photos/Videos of children attending these programs may be used for reasonable promotional purposes by Grasshopper Soccer. TERM FEE $ __________ Please Tick: Yes No TOTAL $ __________ Parent/Guardian Signature:▫ __________________________________________▫ .