FOOTBALL ACADEMY REGISTRATION FORM 2016/17
NAME:
DATE OF BIRTH: ____________________________
ADDRESS: ____________________________________________________
PHONE: ________________________ MOBILE:_______________________
EMAIL_________________________________________________________________
PARENT/GAURDIAN NAME:_______________________________________
MOBILE: _____________________________
Medical Information:
Please clearly detail any medical/physical information (past and present) which you consider relevant to the Club’s consideration of your child’s participation in training and matches. This information will be retained in confidence by the club executive and coaches.
___________________________________________________________________
Statement of Permission:
I give my permission for my child to participate in the Saints Football Academy. I authorize the officials of the Koroit Football/Netball Club, where it is impractical to communicate with me to arrange medical or surgical treatment as may be necessary. I agree to meet the costs of any medical or like expenses that are incurred as a result of the above treatment.
DISCLAIMER
I have read the above and understand that the Koroit Football Netball Club does not insure my son/daughter against injury including the use of ambulance service. I accept the responsibility for any costs not claimable through Medicare and understand that it is my responsibility to provide extended private health cover.
PARENT OR GUARDIAN SIGNATURE: ______________________________
APPLICABLE REGISTRATION PAYMENT OF $70 GST INC.
KFNC ANZ Bank Details
BSB: 013 904
ACCOUNT: 213791117
REFERENCE: Name and Saints Academy
OR
CHEQUE PAYABLE TO KOROIT FOOTBALL NETBALL CLUB
OR
PAID BY CASH
For Further information please contact Alistair McCosh on 0448830115 or Adam Dowie 0404145018
