Football Bundaberg: - Apply or Payments

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Terms and Conditions
I acknowledge by submitting this form that the above named child enrolled hereon is in excellent health and may participate in strenuous physical activities including football soccer. I agree to defend and hold Football Bundaberg Inc, Football Wide Bay and Football Queensland, their servants, agents, Volunteers and/or employees and contractor harmless from any and all claims for injuries that may be sustained by the above named child during his or her participation in this sport. Permission is herby granted to Football Bundaberg, Football Wide Bay and Football Queensland to use pictures of the players in any promotional material Permission is granted for the above named child to receive emergency medical treatment, if needed, and I certify that there are no limits to my child’s participation except as stated in writing and included with this application.

Participant Name*:

Address*:

Sex*:

Email Address:

(if under 18) Parent or Guardian Name:

(if under 18) Parent or Guardian Addresses:

Phone Number*:

Alternative Contact Number (eg work):

Mobile:

Participant Age*:

Participant Date Of Birth*:

List Any Medical Conditions*:

Any medications currently being taken*:

Do you have an allergic reaction to either medications; insects or peanuts that you know of.*:

Your Doctor: name and contact number*:

Do you have private Medical Cover*:

Emergency contact (name)*:

Emergency contact (phone)*:

Relationship to participant (eg parent, family, friend):

If shirts included please supply shirt size:

I have read and agree with the terms and conditions as specified above*:

Yes, I agree

Todays Date (DD-MM-YY)*:

Program you are applying for (eg Squirts Club, Sports Med Cadet etc)*:

Verification:

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