New Athlete Intake Form

General Information

Please note that Player Mobile phone and Emergency Contact Ph number collected

will be used for communication via Whatsapp for ease of communication.

Athlete First name *

Athlete Surname *

Date of Birth *

Athlete Email Address *

Gender *

MaleFemale

Athlete Mobile phone *

Athlete Postcode *

How did you find out about us? *

Emergency Contact Information

All program-related communication and invoices will be sent to this email address and phone number.

Emergency Contact Name *

Phone *

Emergency Contact’s relationship to you *

Program you are enquiring about

Power and Pace Services offered

Physio & RehabSport InsuranceFast Bowling - Development Program AssessmentFast Bowling - Action Type AssessmentFast Bowling - FundamentalsFast Bowling - Development ProgramFast Bowling - Youth ProgramFast Bowling - High Performance ProgramFast Bowling - PaceLab Academy Batting - Fundamentals Batting - AdvancedBespoke Program

Athlete Information

Current Work Status *

StudentEmployedAthlete Not working

Occupation

Athlete Currently Playing *

ClubRepGreensGradeShiresStateOther

Athlete Current Club *

Athlete Playing Level *

Rep Div 1Rep Div 2Green ShieldsGrade 5Grade 4Grade 3Grade 2Grade 1NoneOther

Health Fund Details

Will you be claiming the Physio & Rehab sessions via your Health Fund ? *

YesNo

Health Fund Provider Name

Health Fund Membership No

Current Injuries

Any Current Injuries ? *

YesNo

Location of Scans, if any ?

Are you claiming Sport insurance ?

YesNoNot Sure

Payment Options

How will you be paying for the program ? *

Upfront via Bank Transfer Monthly Direct Debit Weekly Direct Debit

Consent

I confirm that above information I have provided is true, complete and accurate. If I choose a program Power and Pace offers, then I will be provided a teambuildr code via my (Athlete) whatsapp and I (Athlete) will be added to the Power and Pace Whatsapp group. *

I grant Power and Pace a non-exclusive, royalty-free license to use photos and videos of me solely for the purpose of promoting Power and Pace programs on social media platforms. *

Signature

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Date

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