1. Staffordshire FA & Staffordshire Cricket Board
Easter Holiday Club 2016
Application Form – Page 2
Name:
Address:
Post Code:
Date of Birth:
Emergency Tel:
Address:
Signed:
(Parent/ Guardian)
Date:
Staffordshire FA & Staffordshire Cricket Board
Disability Holiday Clubs
Where?
Wilnecote Leisure Centre, Tamworth
Stafford Manor High School
Burntwood Leisure Centre
Chesterton Vision Centre
When?
Easter Holidays
Who?
For both boys and girls recommended between
the ages of 5 to 16 with a disability/ impairment.
Participants may on occasions be photographed for media and promotional purpose. Please tick the box if you do not wish photographs of your child to be used in this way.
Medical Details W
Please tick relevant boxes.
Physical Impairment
Hearing Impairment
Learning Difficulties
Visual Impairment
Other please state:
Special Requirements :
Unfortunately we are unable to assist with any child changing during the course.
(Please give details)
Fun games, skills, competitions and much more!!!
Please note: If your child requires emergency medication e.g. insulin to be administrated whilst at the coaching sessions please ensure that you attend with your child on the first session to talk to the coaches.
*Funding for this project is received through Staffordshire county council who may share this information on an anonymous and needs led basis.

2. Please tick venue (s) attending
Price
Please tick venue (s) attending
Tuesday 29th March
Wilnecote Community Leisure Centre
Tinkers Green Road (Indoor)
Wilnecote
Tamworth
B77 5LE
FREE
Wednesday 30th March
Stafford Manor High School
Wolverhampton Road (Indoor)
Stafford
ST17 9DJ
Thursday 31st March
Burntwood Leisure Centre
High Street, (Indoor)
Burntwood,
Staffordshire
WS7 3XH
Friday 1st April
Chesterton Vision Centre (Indoor)
Newcastle
ST5 7JF
Do you want to have fun and make new friends?
Do you want the opportunity to join a local football or cricket club?
Do you want to play like Rooney, Wilshere, Cook or Root?
Are you aged between 5 and 16?
(Older children may be considered)
Our Holiday sessions are accessible for children with a wide range of disabilities including learning disabilities, autism, hearing impairment, Cerebral Palsy, visual impairment and physical impairments.
Our Aiming High clubs will start at 10.30am
and finish at 2.30pm.
Our Aiming High sessions are FREE of charge, however if you book onto a course and fail to attend without fair reason then we will prioritise others bookings on future courses.
It is important that you book prior to attending so that the correct equipment can be brought to the sessions
Please complete both pages of the application form and return to:
Mark Knight,
Staffordshire FA,
Dyson Court, Staffordshire Technology Park,
Beacon side, Stafford, ST18 0LQ
Alternatively, contact Mark Knight at Staffordshire FA on
Tel: or
Please Note:
Unfortunately we are unable to assist with the changing of children or immediate toileting needs during the courses.
If you have any queries or questions please feel free to contact us on the details opposite.