Coogee United Juniors 2012 JUNIOR PLAYER REGISTRATION FORM (1) PLAYER DETAILS First Name
Middle Name
Surname
Home #
Mobile #
Date of Birth
Gender M/F
School
(2) MEDICAL CONDITIONS Does your child has any medical conditions that this club needs to be aware of: Insert "X"
No Yes, please specify
(3) PLAYING HISTORY Returning Player (From same club) Insert "X"
Previous Team:
New Player (Never played before) Transferring Player (From another club)
Previous Club:
(4) COMPETITION Age Group applying for: Boys Teams Born in
2007
2006
5's
6's
Insert "X"
2005
7's
2004
2003
8's
2002
9's
2001
10's
2000
11's
1999
12's
1998
13's
1997
14's
1996
15's
1994 / 1995
16's
18's
OR
Girls Teams Born in
2007
2006
5's
6's
Insert "X"
2005
7's
2004
2003
8's
2002
9's
2001
10's
2000
11's
1999
12's
1998
13's
1997
14's
1996
15's
1994 / 1995
16's
18's
(5) PARENT/GUARDIAN DETAILS Main Contact First Name
Middle Name
Date of Birth
Surname
Relationship to player
Gender M/F
Phone (Home)
Phone (Wk)
Phone (Mob)
Facebook Email Address
P/Code
Suburb
Secondary/ Emergency Contact First Name
Middle Name
Date of Birth
Surname
Relationship to player
Gender M/F
Phone (Home)
Phone (Wk)
Phone (Mob)
Email Address
P/Code
Suburb
(6) SIGNING By signing this form, I agree to the Terms and Conditions of Coogee United Football Club
Name
Signature
Date
(7) NOTES
***OFFICE USE ONLY*** Amount FFA No
Payment Method Cash Cheque
C/C Eftpos
Siblings: Administrator:
$
:00
Receipt No Date Received
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