Application to attend trial

Please complete all sections of this form and indicate which venue and date you will be attending the trial.

Please DO NOT attend a trial without prior booking. Anyone who applied for previous trials must re-register.

Surname:
Forename:
Email:
Age:
School Year:	Please select Year 1 Year 2 Year 3 Year 4 Year 5 Year 6
Date of Birth (dd/mm/yyyy): Please click the button to enter your date of birth.
Team Age:
House No/Name:
Road:
Town:
City:
County:
Post Code:
Home Tel:
Day Tel:
Mobile Tel:
Medical Conditions / Allergies / Medication:
Please select a suitable venue and date University of Derby, Kedleston Road, Derby Wednesday 3rd August 2011. 5:30 - 6:45pm ( School Years 1 - 3* ) from September Wednesday 3rd August 2011. 7:00 - 8:15pm ( School Years 4 - 6* ) from September * Based on school year 2011 - 2012
Please tick this box to be kept informed of future coaching courses.