1. SHROPSHIRE FOOTBALL ASSOCIATION 1 ST 4SPORT QUALIFICATIONS/THE FA COURSE APPLICATION Name of Attendee: _________________________________ Title______ Address: _______________________________________________________________ _______________________________________________________________________ _____________________________________Post Code_________________________ Gender Male/Female FAN (if known): _____________________ Date of Birth______________________________ Tel No: (Home) ___________________________Tel No: (Day)____________________ Emergency No:___________________________________________ (Wife, Partner etc) Club/Organisation________________________________________________________ E-MAIL__________________________________________________________________ Please note unless stated ALL confirmation will be sent via email. If you do not have internet access please advise and your information will be sent in the post. Signature of Attendee ______________________________________________________ Methods of Payment: To book on line www.shropshirefa.comwww.shropshirefa.com Submission of this booking form will constitute an invoice for course costs if payment is not received prior to start of course. *Name of Payer / Club / Organisation_________________________________________ Cheque / Invoice (please circle) Amount £_____________ (per person) Invoice Address:_________________________________________________________ ________________________________________________________________________ _____________________________________Post Code__________________________ Signature of Payer _______________________________________________________ JUNE FEMALE ONLYSHREWSBURY SPORTS VILLAGE Thursday 4th 6.00pm – 10.00pm - Course Introduction / Theory Sunday 7th 9.00am – 5.00pm – Coaching Theory / Practical Monday 8th 6.30pm – 9.30pm – Safeguarding Children Workshop Thursday 11th 6.00pm – 10.00pm – Portfolio sign off / Emergency Aid Sunday 14th 9.00am – 5.00pm – Assessment / Learner Support Level 1 1st4sport Award in Coaching Football Qualification

2. Ethnicity – I would describe my ethnic origin as: Disability – Do you consider yourself to have a disability? Yes / No / Prefer not to say If Yes, what is the nature of your disability? (Please circle) Hearing Multiple Mobility Other Learning Visual Physical Prefer not to say Please tick this box if you do not want to receive information from Shropshire FA Please state any condition(s) requiring medication e.g. Asthma_______________ Please tick if you have an FA first aid qualification____________ Please tick if you have a ‘FA safeguarding children’ certificate______________(Proof will be required) I understand that the course I am applying for will require me to participate as a coach and player and I confirm that I am physically prepared to participate YES/ NO I accept that Shropshire Football Association cannot be held responsible for any loss or injury I may sustain whilst taking part in this course. Signed……………………………….. Date…………………………………… Please complete this form and return with your cheque/invoice address to: Football Development Department Shropshire Football Association, Oteley Road, Shrewsbury. SY26ST Email: zoe.griffiths@shropshirefa.com Cheques payable to “Shropshire Football Association’ Please write ‘Coach Ed’ on back of cheque. CLOSING DATE: 1 WEEK PRIOR TO START OF COURSE Rules and Conditions: Cancellations must be received no later than 48hrs before the start of the course by either letter or email or the full charge will be payable. Refunds will not be issued after this deadline. All courses are subject to participants numbers. In the event of a course being cancelled you will be contacted no later than 48hrs before the course is due to run. In the event of this full refunds will be given. Data Protection The information provided by the applicant will be used solely for the purposes of the Shropshire Football Association. If you wish to pay by credit/debit card, complete the information below and either post the form to the address below or telephone the SFA on 01743 362769. This is for payment only. Cardholder Name:…………………………………………………… Card Number (16 digits) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Start Date: _ _ / _ _ End Date: _ _ / _ _Post Code …………………… 3 Digit Security Number: _ _ _