1. Fun games, skills, competitions and much more!!! February Holiday Club 2016 Application Form – Page 2 Name: Address: Post Code: Date of Birth: Emergency Tel: E-mail Address: Signed: (Parent/ Guardian) Date: Staffordshire FA & Staffordshire Cricket Board Disability Holiday Clubs Participants may on occasions be photographed for media and promotional purpose. Please tick the box if you do not wish photographs of your child to be used in this way. Medical Details Physical ImpairmentHearing Impairment Learning DifficultiesVisual Impairment Other please state: Special Requirements : Unfortunately we are unable to assist with any child changing during the course. (Please give details) Please tick relevant boxes. Please note: If your child requires emergency medication e.g. insulin to be administrated whilst at the coaching sessions please ensure that you attend with your child on the first session to talk to the coaches. *Funding for this project is received through Staffordshire county council who may share this information on an anonymous and needs led basis. W Where? Wilnecote Leisure Centre, Tamworth Stafford Manor High School Burntwood Leisure Centre YMCA North Staffordshire When? February Half Term Who? For both boys and girls recommended between the ages of 5 to 16 with a disability/ impairment.

2. Please complete both pages of the application form and return to: Mark Knight, Staffordshire FA, Dyson Court, Staffordshire Technology Park, Beacon side, Stafford, ST18 0LQ Alternatively, contact Mark Knight at Staffordshire FA on Tel: 01785279831 or 07816536446 Email: mark.knight@staffordshirefa.commark.knight@staffordshirefa.com Please Note: Unfortunately we are unable to assist with the changing of children or immediate toileting needs during the courses. Do you want to have fun and make new friends? Do you want the opportunity to join a local football or cricket club? Do you want to play like Rooney, Wilshere, Cook or Root? Are you aged between 5 and 16? (Older children may be considered) Our Aiming High sessions are FREE of charge, however if you book onto a course and fail to attend without fair reason then we will prioritise others bookings on future courses. It is important that you book prior to attending so that the correct equipment can be brought to the sessions Our Holiday sessions are accessible for children with a wide range of disabilities including learning disabilities, autism, hearing impairment, Cerebral Palsy, visual impairment and physical impairments. Our Aiming High clubs will start at 10.30am and finish at 2.30pm. If you have any queries or questions please feel free to contact us on the details opposite. VenuePricePlease tick venue (s) attending Tuesday 16 th February Wilnecote Community Leisure Centre Tinkers Green Road (Indoor) Wilnecote Tamworth B77 5LE FREE Wednesday 17 th February Stafford Manor High School Wolverhampton Road (Indoor) Stafford ST17 9DJ FREE Thursday 18 th February Burntwood Leisure Centre High Street, (Indoor) Burntwood, Staffordshire WS7 3XH FREE Friday 19 th February YMCA North Staffordshire (Indoor) Harding Road Stoke-on-Trent Staffordshire ST1 3AE FREE