Registration - FREELANCE FUTSAL INT’L

Name*

Given Name

Surname

Date of Birth*

Street Address*

Town/Suburb*

Postcode*

Email address*

Contact Number*

Parent/Guardian Name*

Will be willing to travel for tournaments i.e. Local & International*

Yes

No

Please give further details where required in relation to the previous medical details*

If None Type N/A

Please list all food related allergies*

If None Type N/A

Private Health Cover*

Yes

No

Private Health Insurance Company Name*

If None Type N/A

Private Health Insurance Number*

If None Type N/A

Medicare Card Number & Position*

Medicare Expiry Date*

Do you have a pre-existing injury/condition that is likely to be aggravated by Training/Playing*

Yes

No

Maybe

Please give further details of above Injury/Condition*

If None Type N/A

Do you have Personal Accident & Injury Insurance cover against accident/injury during competitions & associated activities (training/travel)?*

Yes

No

In consideration of the Organisation allowing me to participate, I agree:*

a)To assume all risks arising out of, associated with or related to my participation.

b)To be solely responsible for any injury, loss or damage that I might sustain while participating; and

c)To release the Organisation from liability for any and all claims, demands, actions and costs that might arise out of my participating, even though such risks, injuries, loss, damage, claims, demands, actions or costs may have been caused by negligence of the Organisation

This field should be left blank

Registration Form

Medical Details