£37.50 for the 10 week course

Spring Term Cricket 2013

To pay by debit/credit card.Credit Card/Debit Card number (if applicable):

Expiry Date Issue No/Valid From

Total Amount to be debited £

Name of Cardholder Signature of Cardholder

Please make cheques payable to “Treasurer of the States” Please send with completed form to: Sports Development, Department for Education, Sport and Culture, Fort Regent, St Helier, Jersey, JE2 4UX. Alternatively you may pay by debit/credit card.

Places are offered on a first come, first served basis. Limited availability. Early booking advised.

Cricket Course Application Form - Spring Term 2013

There will be no class during the February half term. All equipment is provided. Please wear a tracksuit and trainers and bring plenty to drink.

Ref: Dates Time Venue School Years

2100 Wednesday 9 January - 20 March 6pm – 7pm Oakfield 3, 4 & 5

2101 Wednesday 9 January - 20 March 7pm – 8pm Oakfield 6, 7 & 8

2102 Friday 11 January - 22 March 6pm – 7pm Langford 3 & 4

2103 Friday 11 January - 22 March 7pm – 8pm Langford 5 & 6

2104 Friday 11 January - 22 March 6pm – 7pm Les Quennevais 3, 4 & 5

2105 Friday 11 January - 22 March 7pm – 8pm Les Quennevais 6, 7 & 8

Name: Date of Birth:

Home Address:

Post Code:

Telephone Day: Evening: Mobile:

E.mail Address:

Emergency Contact Name and Telephone Number:

Please list any allergies and / or medical conditions which may affect your ability to participate in

moderate physical activity, and any statement of special needs, etc:

Course/s requested:

I consent to my son/daughter’s participation. I undertake to see that my son/daughter is provided with the required clothing/equipment where appropriate. To the best of my knowledge, my son/daughter is medically fit to participate in the activities involved and I undertake to inform you in advance of any alteration to this position. Please specify if your son/daughter has any medical problem that we should be aware of.

Parent/Guardian Signature: Date:

We reserve the right to amalgamate or cancel classes if there are insufficient numbers.

Data Protection Law (Jersey) 2005 The information provided by you on this form is required by the Sport & Leisure Division for the purpose of course enrolment and coaching requirements. Children’s information supplied by you may be disclosed to sports coaches. Financial details provided will be securely disposed of upon course enrolment.