SHROPSHIRE FOOTBALL ASSOCIATION COURSE APPLICATION FA LEVEL 2 BLOCK 1 – How We Coach Price - £49 Charter Standard Clubs £59 Non Charter Standard Clubs MAY SHREWSBURY Tuesday 23rd May, 6.00pm – 9.30pm Wednesday 24th May, 6.00pm – 9.30pm Tuesday 30th May, 6.00pm – 9.30pm Wednesday 31 May, 6.00pm – 9.30pm Saturday 3rd June, 9.00am – 5.00pm Sunday 4th June, 9.00am – 5.00pm 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) E-MAIL__________________________________________________________________ CLUB: ALL CONFIRMATION AND DETAILS WILL BE SENT BY EMAIL Signature of Attendee ______________________________________________________ Methods of Payment: Cheque made payable to Shropshire FA 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. Cardholder Name:…………………………………………………… Card Number (16 digits) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Start Date: _ _ / _ _ End Date: _ _ / _ _ Post Code …………………… 3 Digit Security Number: _ _ _ Shropshire Football Association, Oteley Road, Shrewsbury. SY2 6ST

Signed……………………………….. Date…………………………………… 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…………………………………… 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. Please complete this form and return with your cheque/invoice address to: Coach Education Department Shropshire Football Association, Oteley Road, Shrewsbury. SY26ST Email: harry.coles@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