* 1. Please enter the following parent/carer or provider contact details:

* 2. Please enter the number of children you would like to register for the clinic:

* 3. Please enter the nature of your child's disability:

* 4. Do you require wheelchair access? 

* 5. Do you consent with your contact details being used by AFL NSW/ACT, Sports NSW and the Sydney Swans to send communication regarding their respective programs?