Elementz Pakuranga Registration Form

Elementz Touch Rugby 2023/24 Season

Senior Registration Form

Pakuranga Module 2023-24

elementzsports.co.nz

Pillars (Foundations)

People, Quality, Development, Commitment

Values

Trust, Respect, Accountability, Discipline, Enjoyment

Mission Statement

Using sport to empower people to grow as individuals and contribute to their team, Whanau & communities.
Player Information
Player Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Ethnicity*
Guardian / Parents Names if under 18

First NameLast Name
E-mail*
Secondary E-mail
example@example.com
YesNo
YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*

Area CodePhone Number
Name of last years team if any
SENIOR GRADES

Open Menz
Open Womenz
Develz
Bit Rusteez (social mens)
Old Boyz (over 35s)
Open MenzOpen WomenzDevelzBit RusteezOld Boyz
YesNo
If yes please choose size required:
Emergency Contact
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
YesNo
Please describe
Parental Permission For Emergency Treatment if Under 18

In the event of illness or accident, I give consent to secure any and all necessary emergency medical care for my child.
YesNo
Permission For Photos

During the season we capture photos of the POD, Awhi awards and team photos. Elementz use these on social media.
For myselfFor my childBoth
FEES & PAYMENT

Club Fee: $15 per player (one off fee)

Module Fee: $55

Playing tee: $30

Once we have received your registration, please allow 7 working days for an invoice to be emailed through to you at the email address you have provided.
After completing this form, please click Submit Form. You will receive a confirmation email. If you do not receive the email within a few minutes, please check your spam; otherwise, please contact us at elementzsportzgroup@gmail.com

We will be in touch withing 7 working days with an invoice for you to pay your fees.
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