Chiswick Lacrosse The Friendly Club

Week 2 Aug 22nd to 26th  

Any comments or questions


Address 1

Address 2



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. Sat 20th  Aug 9.30 to 5.30 & Sun 21st  Aug 9.30 to 5.30 (Cost £240 incl mentoring)

Payment Method

Mon Aug 22nd

Tue Aug 23rd

Wed Aug 24th   

ThuAug 25th   

Fri Aug 26th   

ELA membership number

Application form for Lacrosse Coaching Level 2 2016

Sat 20th and Sun 21st  Aug

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