1. Application Form- Regional Course/Event Details (if applying for more than one course from different authorities, please complete separate forms for each authority ) Please complete the form fully in block capitals and return to the relevant regional office/Local authority office; you must complete all sections below to be accepted onto the course; these details are required in order to retain your qualification on the Scottish FA database. Full payment must also be received with this application for you to participate in this course. Title:MrMrsMissMsSFA ID Number (if known): Surname:Name: E-mail: (This is essential as all correspondence for this course is via email) Home telephone:Daytime telephone: Full address: Postcode: Date of Birth:Place of Birth: Club:Quality Mark Approved tick if applicable Please provide details of any medical conditions, disabilities, dietary requirements or specific needs: Early Touches (£40)Coaching Young (£55) Coaching in the Game (£55) Development Activities (£40)Coaching Footballers 13+(£55) Goalkeeping Certificate (£40) CPD Event*VariesAny other Event*Varies Date of Event/Course:Venue:Cost: * If Event please give name of event: Page 1 of 2 PTO Cash:Cheque:Other: Payment Details

2. Terms and Conditions 1.Applications should be received prior to course commencement. 2.Fees must be fully paid on application to secure a place on the course. 3.We reserve the right to cancel or amend the arrangements for any course. In this event, any course member unable to transfer to an alternative course venue will be issued with a full refund 4.Intimation of cancellation on a course member’s part for certificate courses must be given in writing and must be received at least 7days prior to course commencement. In this event a full refund will be given. Cancellation within the 7 day period prior to a course will not be refunded. 5.The validity of the coaching qualification is limited in time to 4 years. Unless you progress to another level within that 4 year period you will be required to repeat the course and re-new your qualification. 6.The Scottish FA is strongly committed to equal opportunities for all participants involved in its coach education programme. It is the policy of the Scottish FA to ensure that all course participants receive equal treatment regardless of age, gender, marital status, employment status, social class, colour, race, ethnic or national origin, religious belief or disability. 7.The course member agrees to abide by the rules laid down by the Scottish FA and its Staff 8.Your information will be used by the Scottish FA to maintain and update course attendance records 9.Quality Mark discount is only permitted if you are taking the course within your own region I do not wish to be included in future mailings on coach education From time to time, photographs and video footage may be taken during events/courses for promotional purposes. If you wish to opt out of this please tick the box. The Scottish FA is seeking to recruit volunteers into the game. If you are interested in receiving information regarding volunteering opportunities please tick this box Application Form- Regional I have read and agreed with the Scottish FA’s terms and conditions in respect of Coach Education Signed:Date: The Scottish FA is committed to promoting equality and eliminating discrimination. We seek this information for monitoring participation in football only and will not use it for any commercial purpose or share it with any third party. Please mark (X) in ONE box which best describes your ethnicity □ White Scottish□ Polish□ Bangladeshi□ African □ Other British□ Pakistani□ Chinese□ Caribbean □ Irish□ Indian□ Arab□ Mixed Race □ If ‘other’ please specify:□ Prefer not to say Please mark (X) in ONE box which best describes your religious denomination □ Christianity□ Judaism□ Hinduism□ None □ Islam□ Buddhism□ Sikhism □ If ‘other’ please specify:□ Prefer not to say Do you consider yourself to have a disability?□ Yes□ No□ Prefer not to say Equity Monitoring Application Form CompleteQuality MarkYesNoPayment Received: For Office use only: