South Bromsgrove Soccer School

Child's Name

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Date of Birth

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Address

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Doctor's Name & Address

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Contact Name & Number

1st Contact* 2nd Contact* 3rd Contact*

Any Medical Information

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Any other information we would need to know

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Booking Dates

Select one of the following*Tuesday 21st FebruaryWednesday 22nd FebruaryThursday 23rd February

Payment £30 per day / £75 for 3 days

Select one of the following*Cheque (payable to South Bromsgrove High)BACS (please put name as reference) Bank: Lloyds Bank plc Account name: South Bromsgrove High Sort code: 30-63-94 Account number: 27726260

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