-
8/10/2019 !Booking Form - Step Into Coaching - Rainham School
for Girls - 150215 -...
1/3
NETBALL LONDON & SOUTH EASTCOACHING WORKSHOP BOOKING
FORM
Please complete all information on this booking form:
Workshop Nam! S"p #$"o Coa%h#$
'$( ! Ra#$ham S%hool )or G#rls
Da"! S($*a+ ,-"hF.r(ar+ /0,-
Ca$*#*a" Nam (Ms1Mr1M#ss1Mrs2!
A))#l#a"#o$ N(m.r 1 N".all ID No!3#) appl#%a.l2This information
is essential if you wish to receive thediscounted affiliated course
rate.(Please contact Membership Dept on 01462 442344if you have any
queries relating to affiliation!
Ca$*#*a" A**rss!
Co$"a%" Tlpho$ No Hom! Mo.#l!
E4ma#l a**rss!
Da" o) B#r"h!(Applicants must be 16 years of age
Emr$%+ Co$"a%" Nam!
Emr$%+ Co$"a%" No!
M*#%al I$)orma"#o$(e.g epilepsy! asthma! diabetes! allergies
etc
Please list below any "etball related awards # $ualifications
you currently hold:
A5ar*s L6l Da" a%h#6*
%&' )ourse *ooking +orm Page ,of 7
Course Referencember:
Internal use only
-
8/10/2019 !Booking Form - Step Into Coaching - Rainham School
for Girls - 150215 -...
2/3
Please provide information on the individuals or groups you have
coached in the last 1,to 1- months
L6l o) pla+rs a$* 5hr +o( %oa%h No8 o) ho(rs%oa%h* pr 5k
hat further awards # $ualifications would you be interested in
attending/
0000000000000000000000000000000000000..
0000000000000000000000000000000000000..
Are you able to actively take part in the game of "etball/ es
"o
2f no! please detail the reason: 0000000000000000000000.0
000000000000000000000000000000000.0.000
3Plas $o"for some practical workshops participants may need to
be actively involvedin netball skills and drills. 2f you are not
able to actively take part! please inform thecourse organiser at
the point of booking.
Pa+m$"!*y che$ue onlymade payable to:L&SERNA or Lo$*o$ &
So("h Eas" R#o$ N".all Asso%#a"#o$The candidate4s name must be
clearly printed on the back and returned with the bookingform
to:
Ma""h5 GorN".all Lo$*o$ & So("h Eas"Br($l U$#6rs#"+ Spor"s
C$"rK#$s"o$ La$U9.r#*
UB: 7PH
Please tick the bo5 if you are willing for "etball %ondon &
'outh ast to use yourpersonal data to contact you about future
coaching workshops.
Please tick the bo5 if you would like to be mentored to progress
your coaching$ualifications.
F($*#$!2f your )lub! )ounty or another agency is funding your
course attendance! please askthem to clearly state your name on the
back of the che$ue.
Ca$%lla"#o$ Pol#%+:e$uests to cancel a booking should be
directed to your )ourse 7rganiser and will beconsidered on an
individual basis
%&' )ourse *ooking +orm Page /of 7
-
8/10/2019 !Booking Form - Step Into Coaching - Rainham School
for Girls - 150215 -...
3/3
Are you male or female?
Date of Birth
What is your ethnic group?
White White British Black or BlackBritish
Black Caribbean African
Other Black
Mixed White & Black Caribbean
White & Black African
White & Asian
Other Mixed
Chinese or OtherEthnic Group
Chinese
Other Ethnic Group
Asian or AsianBritish
Indian Pakistani Bangladeshi
Other Asian
refer not to say
!nkno"n
he !isabilit" !iscri#ination Act $%% defines a disabled person
as an"one 'ith a (ph"sical or #ental
i#pair#ent 'hich has a substantial and long)ter# ad*erse effect
upon his+her abilit" to carr" outnor#al da" to da" acti*ities,-
Do you consider yourself to ha#e a disa$ility?
%f &es' "hat is the nature of your disa$ility?
.isual /earning 0earing Multiple
Ph"sical Other Prefer not to sa"
FOR INTERNAL USE ONL;
Any further action re$uired:
00000000000000000000000000000000000000000000000
00000000000000000000000000000000000000000000000
00000000000000000000000000000000000000000000000
)he$ue received: es "o
Place confirmed es "o
%&' )ourse *ooking +orm Page 7of 7
