Participant Application Form - The Shire Of Peppermint Grove
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2SPORTSLINK PROGRAM
Application Form
Attendance Details
Venue:
Presbyterian Ladies’ College – Junior School Sports Centre & Astro Turf Area
Address: McNeil Street Peppermint Grove
Cost:
$60 for the complete 6 week course
Dates:
Monday 20 February to Monday 3 April
Time:
4.00 pm – 5.00 pm
Please refer to the enclosed PLC Site Map for directions and parking
Please note: Instructors are responsible for instruction and group supervision. Carer support is required
for participants requiring one to one carer assistance alongside coach and student volunteers.
Participants Details
_________________________
______________________________
Given Names:
Surname:
___________________________________________________________________
Address:
_____________________________
___________
____________
Suburb:
State:
Postcode:
__________________________
___________
DOB:
Age:
Sex:
Male / Female
_________________________________________
Name of carer in attendance (if applicable):
Next of Kin
______________________
________________________________
Given Names:
Surname:
_______________________________________________________________
Relationship:
_______________________
_______________________________
Phone (H):
Phone (W):
__________________________
_______________________________
Phone (Mob):
Fax:
___________________________________________________________________
Email:
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Parent category: Life