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Player Registration Form Name: __________________________________________ DOB: ___/____/_____ Address: __________________________________________________________________________ __________________________________________________________________________________ Phone: __________________________ Mobile: __________________________________________ Email: ____________________________________________________________________________

Next of kin Details Name: ___________________________________________________________________________ Address: _________________________________________________________________________ _________________________________________________________________________________ Mobile Contact: _______________________ Work Contact: ________________________________

Medical Details Allergies/Conditions: ________________________________________________________________ _________________________________________________________________________________ Past major injuries: _________________________________________________________________ _________________________________________________________________________________ Doctor: ___________________________ Contact: ________________________________________

All of this information is true and correct to the best of my ability Player name: ___________________

Signature: _________________ __/__/2011

This information will be dealt with in a private and confidential manner and will only be used for club purposes and in the event of a medical emergency Office Use Only

Entered by:

Membership Paid $130 (___/___/2011)

$150 (___/___/2011)

$50 (___/___/2011)

player registration form  

player registration form

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