Registration Form for Mildura Soccer Academy

Child’s first name: *

Child’s surname: *

D.O.B: *

Age:

Preferred name:

Gender: *

Male

Female

Child's school:

Class:

Year:

Address:

1813 Southside Lane

Post code:

Primary contact first name: *

Surname: *

Relationship:

Address: *

1813 Southside Lane

Contact number: *

Work number:

Email address: *

Occupation:

Are there any other contact restrictions?:

Yes

Details:

Gwendolyn Peterson

Secondary contact first name:

Surname:

Relationship:

Address:

Gran Via de Hortaleza 58

Contact number:

Work number:

Email address:

Occupation:

Custody of the child is with:

Primary contact

Secondary contact

Both (joint custody)

Other

Contact no.1 name:

Relationship:

Address:

1813 Southside Lane

Mobile number:

Work number:

Contact No.2 name:

Relationship:

Address:

5 Hydro Ct Mildura 3500

Mobile number:

Work number:

I, hereby consent and grant permission to the following persons to collect my child (Must be 18 years or over):

asdasdasdaaaaaaaaaaaaaaaaaaaaaa

Doctor's name:

Doctors address:

asdasdasdsadasd

Doctor Phone Number:

Allergens severity: *

Very high

High

Medium

Low

Allergen's Name:

Medical condition(s) if any:

Does your child have any dietary requirements?:

Yes

Special needs:

Specific likes/dislikes:

N/a

Medication (Please list any medication your child takes regularly and the dosage):

N/a

Does your child have any special educational needs (SEN)?:

Yes

If your child has any learning difficulties/disabilities or requires additional assistance, please list them here:

N/a

Any other relevant information we may need to be aware of ?:

N/a

Secret password:

Other Religion:

First language:

English. But can understand Filipino language.

Any other relevant information:

N/a

Please read our Terms & Conditions View T&C's

Any other instructions : Please send a copy of your child’s immunization records via Cheqdin’s registration messages section in your web portal login or email it to centre’s email ID. For more details, please visit our website: www.INSERT-YOUR-WEBSITE-ADDRESS-HERE.com.:

Declaration :

I accept the terms and conditions of Mildura Soccer Academy

Yes No

Full Name of Parent/Carer:

Digital Signature

Beverly Echanes

Date & time:

17, Apr 2021 01:00 am

Mildura Soccer Academy

Child Details

Parental Responsibility

Emergency Contacts

Medical Info

Other Details

Consents

Terms of Service