Registration Form
Player Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Gender
*
Male
Female
Parent/Guardians Name
*
First Name
Last Name
Address
City
E-mail
*
Phone Number
-
Area Code
Mobile
Location
*
Winmalee
Rydalmere
Other
Age Group
*
3 - 5 years old
Kit Size
3
4
5
6
7
Medicare Card Number
Street Address Line 2
City
State / Province
Postal / Zip Code
Does your child suffer from any of the following
*
Epilepsy
Heart Conditions
Asthma
Diabetes
Blackouts
Migraines
None
Other
Allergies to
*
Penicillin
None
Other
Is your child on any form of ongoing medication?, if so please state
Street Address Line 2
City
State / Province
Postal / Zip Code
What special care is recommeded?
Street Address Line 2
City
State / Province
Postal / Zip Code
Payment Method
*
EFT/ Bank Transfer
Cash
Waiver
The undersigned in their capacity as parent/guardian of the above child acknowledges that they have read and understood the Terms & Conditions stated by Soccer 4 Tots and that this project is organised and managed by staff, and hereby waives any claim against Soccer 4 Tots, and their affiliated companies in connection with Soccer 4 Tots project he is being enrolled to.
Consent to Medical Attetion
Where the Coach or Club Management is unable to contact me, or it is impracticable to contact me, I hereby five permission to the Coach or Club Management to seek treatment for my child at a hospital, or to call a Doctor and/or ambulance and/or dentist during an emergency and agree to pay all relevant costs involved.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
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