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PLEASE LIST DETAILS OF PREVIOUS PLAYING / FOOTBALL EXPERIENCE (if applicable)

CLUB

POSITION

DATE

LEARNING / MEDICAL INFORMATION (if applicable) if you have any learning or medical conditions which may limit / hinder your involvement or participation in coaching activities, you are obliged to declare any relevant, current or previous injuries / illnesses. If you are diagnosed as an asthmatic, diabetic or epileptic, or have any allergies that the course staff needs to be aware of, you must advise us accordingly. Please note, a declaration of injury or illness does not automatically preclude you from any course and such information will be kept confidentially.

You should further be aware that if you are on a regular course of medication for any condition, you must have sufficient medication to cover you throughout the course. Although first aid cover is provided (where applicable) during courses, no doctor is available to replenish regular medication, nor is there any facility to deliver medical treatment for chronic (longstanding) medical conditions.

Please attach any relevant information regarding the above Medical Information with your Application Form. For further information on the FA Learning Equality Policy, please see the National Course Planner or visit www.TheFA.com/FALearning

PLEASE LIST ANY MOBILITY, DIETARY, COMMUNICATIONS OR OTHER SPECIAL REQUIREMENTS YOU MAY HAVE THAT WE CAN ASSIST YOU WITH ON THE COURSE (if applicable)

PAYMENT DETAILS Book by 31 March 2009 to qualify for a discount and book online by credit or debit card to receive a further 10% discount

All Course Fees include Tuition, Residential Accommodation, Meals, Resources and VAT (unless otherwise stated)

Please note that you may be required to share a room

Please find enclosed a cheque payable to ‘FA Learning Ltd’ for

£

_________________

Payments via cheque do not secure the 10% discount, and a place is not held for you until your application form and payment are received

Please charge my Visa / MasterCard / Access / Switch for

£

_________________

Account No

Valid To

Switch Issue No

Security Code (last 3 digits on back of card)

NB: Those candidates who require a receipt for their payment should inform us in writing with the Application Form. Invoicing is NOT ACCEPTED as a method of payment

APPLICATIONS RECEIVED WITHOUT PAYMENT WILL NOT BE CONSIDERED

In order to benefit from the FACA members discount you must enter your membership number. We are unable to confirm a place without either full payment or a FACA number

FACA MEMBER? (Please tick)

YES NO

FACA MEMBERSHIP NUMBER

RETURNING THE APPLICATION FORM All FA Learning Courses: Please complete and return this form, with payment, to: FA LEARNING NATIONAL COURSES, THE FOOTBALL ASSOCIATION, 25 SOHO SQUARE, LONDON W1D 4FA

APPLICANT DECLARATION

I agree to abide by the Course regulations, and understand that neither FA Learning, nor the Authority which provides the facilities, is under any liability in respect for any injury that I may sustain, save where such injury or death is as a direct result of the negligence of FA Learning Ltd.

I declare that the information given in this application is correct and complete.

For FA Diploma TOI & Fitness Trainers Course Applications

Please Insert One Passport Size Photograph

SIGNATURE

DATE

DATA PROTECTION

FA Learning will process your information in accordance with our Privacy Policy, which is available online or at the address above, and the Data Protection Act 1998.

  • Please tick this box if you would like to receive future information from The FA on matters other than FA Learning. If you do not you

will not be able to receive information about any of our special offers or promotions.

  • Please tick this box if you would like to receive information from our group companies or business partners.

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