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									Pacific Soccer Academy Application Form
Please print this completed Academy Application Form and post or fax together with your payment details to:
Pacific Soccer, Po Box 239, Manly NSW 2095, (Australia)
Phone: (02) 9977 2992
Fax: (02) 9977 0376
ABN: 98 056 624 492


Applicant Details:
 Name:

 Address:

 Suburb:                                                   Postcode:                          Contact No.:

 Age:                   Sex: M / F     Club that you play for:


Academy Details:
Please √ Academy box that you wish to attend:


              Frenchs Forest              Castle Hill                  Lane Cove                   Hurstville                       Lane Cove

Day / Date    Sunday Mornings             Tuesday Afternoons           Wednesday Afternoons        Thursday Afternoons              Friday Afternoons
              05.02.06 to 12.03.06        07.02.06 to 14.03.06         08.02.06 to 15.03.06        09.02.06 to 16.03.06             10.02.06 to 17.03.06

Address       Forest High School          Castle Hill High School      Pottery Green Park          Hurstville Boys High School      Pottery Green Park
              Frenchs Forest Road         Castle Street                Phoenix Street              Kenwyn Street                    Phoenix Street
              Frenchs Forest              Castle Hill                  Lane Cove                   Hurstville                       Lane Cove

 Session 1    9.00am to 10.00am           4.00pm to 5.00pm             4.00pm to 5.00pm            4.00pm to 5.00pm                 4.00pm to 5.00pm
              6 to 8 yrs                  6 to 8 yrs                   6 to 8 yrs                  6 to 8 yrs                       6 to 8 yrs



 Session 2    10.15am to 11.15am          5.15pm to 6.15pm             5.15pm to 6.15pm            5.15pm to 6.15pm                 5.15pm to 6.15pm
              9 to 12 yrs                 9 to 12 yrs                  9 to 12 yrs                 9 to 12 yrs                      9 to 12 yrs



 Cost         $95 inc. GST Per Term       $95 inc. GST Per Term        $95 inc. GST Per Term       $95 inc. GST Per Term            $95 inc. GST Per Term

 Payment Details: (Please Tick)

Enclose payment now by: Cheque              Money Order             Mastercard              Bankcard            Visa

CARD NUMBER                                                                            EXPIRY DATE



CARD HOLDERS NAME: ______________________________________

AMOUNT: __________________                                       SIGNATURE: _____________________________________________

CONSENT FORM: I, the undersigned, approve of this application and in doing so do agree that the Pacific Soccer Academy and its
officers and servants are free and clear of all responsibility whatsoever for any injury or illness that may occur during the applicants
participation in the above mentioned activity.
Data Protection Statement and Consent
If you do not wish to receive any information about our services and products please tick this box

Signature of Parent or Guardian: ________________________ Date:_____________________________

								
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