Junior Football

Player Name*

First Last

Date of Birth*

Email (for all correspondence to be sent to)*

Home Address

Mobile*

School

Year level in 2021*

Age group

Competition played 2019 & 2020

Medical Information

Next of Kin / Emergency Contact

First Last

Contact Number

Relationship

Doctor's Name & Clinic

Doctor's Phone Number

Medicare Number

Private Health Insurance

If Yes, fund name & member number:

Ambulance Cover:

If Yes, member number:

Dietary requirements / allergies

Please allow us to plan for pie nights, club BBQs & Thursday night teas.

Medical Conditions/ Current Injuries

Please tick if you suffer from any of the following:

If Yes to any of the above, please indicate treatment if necessary or elaborate:

I allow photos taken to be used for media purposes:*

Parent / Guardian if player is under 18 years of age*

Date