1. Fun games, skills, competitions and much more!!! Half Term Holiday Club 2012 Application Form – Page 2 Name: Address: Post Code: Date of Birth: Emergency Tel: E-mail Address: Signed: (Parent/ Guardian) Date: Staffordshire FA and Staffordshire Cricket Disability Multi-Sports Half Term Holiday Clubs 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 Physical ImpairmentHearing Impairment Learning DifficultiesVisual Impairment Other please state: Special Requirements : Unfortunately we are unable to assist with any child changing during the course. (Please give details) Please tick relevant boxes. 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. When? Tuesday 30 th October Wednesday 31 st October Thursday 1 st November 10.30am – 2.30pm Where? Wilnecote Community Leisure Centre Newcastle under Lyme College Cheslyn Hay Leisure Centre For further information please turn read on. Who? For both boys and girls recommended between the ages of 5 to 16 with a disability/ impairment. All Aiming High sessions are free of charge!

2. Please complete both pages of the application form and return to: Mr Jamie Leaning, Staffordshire FA, Dyson Court, Staffordshire Technology Park, Beacon side, Stafford, ST18 0LQ Or contact Jamie Leaning at Staffordshire FA on Tel: 01785 256994 or 07816536446 Email: jamie.leaning@staffordshirefa.comjamie.leaning@staffordshirefa.com October Half Term 2012 Application Form – Page 1 You can now book your FREE place online at the following links below: Please Note: Unfortunately we are unable to assist with any child changing during the courses. Do you want to have fun and make new friends? Do you want the opportunity to work in a team or join a local club? Do you want to play like Rooney or Flintoff Are you aged between 5 and 16? (Older children may be considered) All Aiming High sessions are FREE It is important that you book prior to attending so that the correct equipment can be brought to the sessions Aiming High, in partnership with Staffordshire FA and Staffordshire Cricket have organised a multi sports half term holiday club for children with a range of disabilities. The Holiday Club will be made accessible for all disabilities ranging from Learning, Hearing Impairment, Cerebral Palsy, Visual impairment and Physical Impairment. The Aiming High clubs will start at 10.30am and finish at 2.30pm. Please note we will only contact you if the course is cancelled, returning the entry form is your confirmation* If you have any queries or questions please feel free to contact us on the details opposite. VenuePricePlease tick venue attending Tuesday 30 th October Wilnecote Community Leisure Centre (Indoor) Tinkers Green Road Wilnecote Tamworth B77 5LE www.staffsfa309.eventbrite.co.uk FREE Wednesday 31st October Newcastle under Lyme College (Indoor) Knutton Lane Newcastle under Lyme Staffordshire ST5 2GB www.staffsfa319.eventbrite.co.uk FREE Thursday 1 st November Cheslyn Hay Leisure Centre (Indoor) Saredon Road Cheslyn Hay West Midlands WS6 7QL www. Staffsfa110.eventbrite.co.uk FREE