Name

Current school or college

Address 1

Address 2

Town

County

Post code

Date of birth

Home Phone

Mobile phone

Email address please

Highest playing experience

Total amount  to pay:    £135

Medical conditions and/or medications

Any comments or questions

Receipt of form and of payment will be made as swiftly as possible by email or phone if no email address is given

If paying by cheque, please make it payable to ‘Chiswick Lacrosse’ and send it to

Chris Southwell, Bryn Deri, Haverfordwest, Pembrokeshire, SA62 6ND

or pay by transfer to: Midland Bank - Chiswick Lacrosse - Sort Code: 40-44-39 - account number  - 81635638  please quote your name as reference.

I wish to do the level 1 coaching course. 12th, 13th

I am available for the following week’s mentoring and assessment

I understand the coat to be £135 including the mentoring

Payment Method

English Lacrosse Membership Number

Application form for Lacrosse Coaching Level 1 2017

Sat 12th and Sun 13th Aug


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Chiswick Lacrosse The Friendly Club