Chiswick Lacrosse The Friendly Club

Chris Southwell

Chiswick Lacrosse

Brynderi

Pembrokeshire

SA62 6ND

07958200128


Week 2 Aug 20th to 24th  

Any comments or questions

Name

Address 1

Address 2

Town

County

Post code

Date of birth

Home Phone

Mobile phone

Email address please

Highest playing experience

Please confirm the days in week 2 that you will be available for mentoring and testing.  

Medical conditions and/or medications

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

The level 2 coaching course with a week’s mentoring and testing - £240.

Please send a cheque payable to ‘Chiswick Lacrosse’ 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 2 coaching course. Sun 19th   Aug 9 to 5.30 (Cost £240 incl mentoring)

Payment Method

Mon   

Tue  

Wed    

Thu    

Fri   

ELA membership number

Application form for Lacrosse Coaching Level 2 2018

Sun 19th Aug


Use Tab key to move through form fields