Waitakere United - Grassroots Registration

Please complete the form to register.

Waitakere United Grassroots Football January 2012 Hosted by Waitakere United Head Coach Neil Emblen and Fijian superstar Roy Krishna

January 2012 23rd,24th,25th,26th. Glen Eden Intermediate, Glen Eden

Name:
Club:
Address:
Phone Number:		Age:
Email Address:

Option selected.

Option 1

6 years & under 4 half days

9am - 11am 23rd - 26th Glen Eden

$70.00

Option 2

6 - 12 yrs 4 full days

9am - 1pm 23rd - 26th Glen Eden

$100.00

Payment can be made by Internet Banking 03 0155 0605637 000 Put your name as the reference -Or -

Post payment to Soccer Program P O Box 121 099 Henderson
Please make cheques payable to Waitakere United for the full amount.

Participants in the School Holiday Coaching Program will need Football, Boots, Soccer Shorts, Wet Weather Jacket, Socks and Shin Pads, Sun Block and your own drink bottle & snacks box. Goalkeeper gloves for Goalkeepers.

Enquiries to admin@waitakereunited.co.nz Phone Rex Dawkins 021 974469 Fax 838 4617