ANDREWS FARM JUNIOR SOCCER CLUB

PLAYER INFORMATION FORM

2013
PLAYERS NAME: .......................................................................

Existing player

DATE OF BIRTH: ......................................

(Please print)

PLAYER AGE GROUP:...............................................................

COACH: ....................................................

(e.g. under 10s)

PleaseTurn Over

ADDRESS: ...........................................................................................................................................................
........................................................................................................ POST CODE: ..............................................
MOTHER / GUARDIANS NAME: ........................................................................................................................
CONTACT PHONE NO: .................................................... MOBILE: ................................................................
FATHER / GUARDIANS NAME: .........................................................................................................................
CONTACT PHONE NO: .................................................... MOBILE: ................................................................
EMAIL ADDRESS: .......................................................................

EMERGENCY PHONE (IF PARENTS / GUARDIAN CANNOT BE CONTACTED)

NAME: ................................................. PH: ......................................... RELATIONSHIP: ...............................
NAME: .................................................. PH: ......................................... RELATIONSHIP: ...............................
DOCTORS NAME: ................................................................ PHONE: ...............................................................
I ACKNOWLEDGE THAT IN THE EVENT OF AN EMERGENCY AN AMBULANCE WILL BE CALLED
for my child and that I am responsible for all costs incurred
.........................................................

Parent / Guardian Signature

MEDICAL CONDITIONS

___/___/___ Ambulance Cover

Yes/No

Date

INSTRUCTIONS IN THE EVENT OF AN EMERGENCY

EPILEPSY

YES / NO

............................................................................................

FAINTING / DIZZY SPELLS

YES / NO

............................................................................................

YES / NO

............................................................................................

EYE DISORDER

YES / NO

............................................................................................

SPEECH DISORDER

YES / NO

............................................................................................

HEART DISORDER

YES / NO

............................................................................................

RESPIRATORY DISORDER

YES / NO

............................................................................................

CHRONIC ILLNESS

YES / NO

............................................................................................

ALLERGIES

YES / NO

............................................................................................

(OR OTHER SUDDEN LOSS OF CONSCIOUSNESS)

EAR DISORDER
(PARTICULARLY DRAINAGE TUBES OR DEAFNESS)

(PARTICULARLY ASTHMA)

(INSECT BITES & STINGS)

OTHER RELEVANT MEDICAL INFORMATION ..................................................................................................

PLAYER AGE GROUPS

1998

Under 15s

1999

Under 14s

2000

Under 13s

2001

Under 12s

2002

Under 11s

2003

Under 10s

2004

Under 9s

2005

Under 8s

2006

Under 7s

2007

Under 6s

2008

Development Squad
( 3yrs to 5 yrs of Age)