LifeSkills Registration Form Social Sports

Personal Details

Your name(Required)

Name Surname

Date of birth(Required)

How would you describe your gender?

Male

Female

Prefer not to say

Other

Your address(Required)

Street Address Suburb Postcode

How can we reach you?

How can we get in touch?

Your email address(Required)

Your phone(Required)

Preferred method of contact(Required)

Person responsible for paying invoices(Required)

Name Surname

Organisation

Phone(Required)

Email(Required)

Program Cost and Dates

CLA participants $120 per 12-week term. NON CLA GUESTS $144 per 12-week term. You will be invoiced prior to the commencement of each term. Participants must be enrolled and pay in full at the start of each term to participate in this program. Note: Please note numbers are limited to venue capacity.

I would like to register for the selected terms

(Please select all the terms you would like to register for.)

Term 1 – 5 February – 23 April (12 weeks)

Term 2 – 30 April – 16 July (12 weeks)

Term 3 – 23 July – 8 October (12 weeks)

Term 4 – 15 October – 18 December (10 weeks)

I am a CLA participant.

Yes

No

Declaration

Declaration: I the applicant or representative, declare the above information is correct in all respects at the time of the lodgement and that I am over 18 years. I understand that NON CLA guests must be supported while attending CLA activities. I understand I must adhere to the CLA Code of Conduct while attending CLA activities.

Signature Full Name(Required)

Date(Required)

Comments

This field is for validation purposes and should be left unchanged.