Northland Futsal Academy Registration

SECTION 1 CHILD'S DETAILS

First name:

Surname:

Age & date of birth:

Gender:

Male
Female

Does your child have any medical considerations (e.g. asthma, epilepsy, anaphylaxis) or special circumstances (e.g. custody issues) that we should know about?

Yes
No

If you answered 'yes' to the above question please provide details that will help us to keep your child safe.

What school does your child attend?

SECTION 2 I.H.A.D SCHOLARSHIPS

Is this player an I HAVE A DREAM scholarship player?

YES - please add details below
NO - continue to SECTION 3

Name of Navigator

Navigator mobile number

Navigator email

SECTION 3 DAYS & TIMES - Please select one or more of the following sessions - age brackets are a guideline only

8 - 9 year old sessions

Wednesday 4:30 - 6:00

All 10-12 year old sessions

Monday 4:30 - 6:00
Tuesday 4:30 - 6:00
Friday 4:30 - 6:00

13-16 year old sessions

Tuesdays 6:00 - 7:30
Fridays 6:00 - 7:30

What are the main reasons for registering your child with Northland Futsal Academy?

To try a new sport for the first time
To have fun and engage with new people (social)
For physical activity/fitness
To develop his/her football skills to a higher level

What football club does your child play for? (if applicable)

SECTION 4 PARENT/CAREGIVER DETAILS

First name

Surname

Relationship to child, e.g. mother, father, caregiver

Mobile contact

Email:

Secondary name & contact phone number in case of emergency

MEDIA RELEASE

I give my permission for my child's photo to be used for promotional and/or coaching purposes on Northland Futsal Academy Limited's Facebook page and/or website.

Yes
No

How did you hear about us?

School newsletter
Flyer
Facebook
NFA website
Word of mouth
Other - please comment below

SECTION 5 PRICES & PAYMENT OPTIONS

One session per week - $125.00 (or $230.00 for two siblings). Two session per week - $230.00 (or $450.00 for two siblings).

Payment can be made by cash, bank transfer or automatic payments.

* Account details: Northland Futsal Academy Ltd - Acc # 38-9017-0827021-00 (Please use your child's surname initials as a reference)

I will make payment by

cash
bank transfer
automatic payment ($25.00 per fortnight)

SECTION 6 T&Cs

* I accept that all foreseeable risks and hazards have been identified and either minimised or eliminated and that Northland Futsal Academy is not liable for any injuries sustained to my child while in attendance at a Northland Futsal Academy training. (Our Health & Safety Policy and Risk Management information is available for you to read at our training sessions). * I give my permission for my child to be attended to by a certified 1st aider and/or emergency services in case of an emergency. (Note: All NFA staff have a current 1st aid certificate).

yes

Do you have any other comments or questions?