Inclusive Sport Event& Telford Player Registration - 15.06.2014

Registration Details

Please complete this online form to register to participate in the following Powerchair Football Inclusive Sport event:

Date: Sunday 15th June 2014
Time: 10:00 - 16:00
Venue: National Sports and Conference Centre, Near Newport, Shropshire, TF10 9AT

All equipment and coaching is provided. If you require any further information, please contact:
Anthony Nweke
WFA Midlands Region Development Officer
E: anthony.nweke@thewfa.org.uk
M: 07972569738

Question Title

* 1. Player details

First name:

Surname:

Email address:

Telephone number:

Question Title

* 2. Postcode:

Question Title

* 3. Gender:

Male

Female

Question Title

* 4. Date of Birth:

Date of Birth

Date

Question Title

* 5. Nature of Impairment / Condition

Muscular Dystrophy (all types)

Cerebral Palsy

Spinal Muscular Atrophy

Spina Bifida

Brittle Bones

Prefer to not answer

Other (please specify)

Question Title

* 6. Ethnicity:

White British

Other White British

White Irish

Other White Background

White and Black Caribbean

White and Black African

White and Asian

Other Mixed Background

Gypsy / Romany / Irish Traveller

Other Ethic Group

Indian

Pakistani

Bangladeshi

Chinese

Other Asian Background

Black Caribbean

Black African

Other Black background

Arab

Prefer not to answer

Question Title

* 7. Emergency Contact details

Emergency Contact Name:

Emergency Contact Telephone:

Relationship to Player (Parent, Carer etc)