Summer Holiday Club 2013
Application Form – Page 2
Name:
Address:
Staffordshire FA and Staffordshire Cricket
Post Code:
Disability Multi-Sports
Summer Holiday Clubs
Date of Birth:
Emergency Tel:
E-mail Address:
Signed:
(Parent/ Guardian)
When?
Every Tuesday, Wednesday
And Thursday
Date:
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.
10.30am – 2.30pm
Medical Details
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)
Where?
Wilnecote Community Leisure Centre
Stafford Sports College
And
Kidsgrove Sports Centre
Who?
For both boys and girls recommended between the
ages of 5 to 16 with a disability/ impairment.
Fun games, skills, competitions and
much more!!!
All Aiming High sessions are free of charge!
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.
For further information please turn read on.
Summer Holiday 2013 Application Form – Page 1
Venue
Week
1
Do you want to have fun and make new friends?
Week
2
Week
3
Week
4
Week
5
Week
6
Do you want the opportunity to work in a team or join a local club?
Do you want to play like Wayne Rooney or Alistair Cook?
Are you aged between 5 and 16? (Older children may be considered)
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 of place*
•To qualify for our Free trips on Week 6 your child must of attended
a minimum of 2 Holiday Course sessions*
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
Please Note:
Unfortunately we are unable to assist with any
child changing during the courses.
If you have any queries or questions please feel free to contact us on the details opposite.
Tuesday
Trips
(Indoor)
Wilnecote Community
Leisure Centre
Tinkers Green Road
Wilnecote
Tamworth
B77 5LE
23/7
30/7
6/8
13/8
20/8
Trips
Wednesday (Indoor)
Stafford Sports
College
Wolverhampton Road
Stafford
ST17 9DJ
Thursday
24/7
31/7
7/8
14/8
21/8
(Indoor)
Kidsgrove Sports
Centre
Forth Avenue
Stoke on Trent
Staffs
ST7 1DR
27/8
28/8
Trips
25/7
1/8
8/8
15/8
22/8
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: [email protected]
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