OFFICE USE ONLY
MONBULK JUNIOR
FOOTBALL CLUB INC.
Season 2017
VCFL Player Reg’n No. …………………..
Amount Paid: FAMILY $…………………
SINGLE $…………………
Player Information
Please indicate if this form is for:
Renewal Membership…………or Initial Membership………or Transferring* from ________________ Club / Auskick
CHILD’s SURNAME:
…………………………………………………….…………….……………….
OTHER NAME/S: ………………………………………….….…………………………….….…….……
DATE OF BIRTH: ..…………………………………
AFL TEAM SUPPORTED: …………………………………..……
How many matches of the 2016 AFL Home and Away Premiership season did you attend live in person? ………
Were you or either of your parents born overseas?
Yes
No
Do not wish to disclose
Player’s Country of birth: ………………………………..…Mother: ………………………………. Father: ………………..……………
Are you from Aboriginal and/or Torres Strait Islander origin? Yes
No
Do not wish to disclose
YOUR ADDRESS: .……………………………………………………………………..……………………………………………….…
……………………………………………………………
POSTAL ADDRESS (If different)
POSTCODE: ………………..………...……
……………………………………………………………………..…………………
…………………………………………………..…………………
HOME TELEPHONE: …………………………..……………………
POSTCODE:
……….…..……….
MOBILE:……………………………………
PREFERRED EMAIL CONTACT: ………………………………………………………………………………………………………
PARENT/CARER
Name:…………………..………………………………….…..…. MOBILE: ………………………………
Name:………………..…………….……………………...…. MOBILE:……………………..………
AN EMERGENCY CONTACT PERSON (If parent/carer is unavailable)
Name……………………………………………………………Telephone: ………………………….……..
Photographs – During the season we will have photos taken at various times which we may then feature
in our club publications / media.
Please TICK BOX if you DO NOT wish to have your child’s photo to be publicised
PLEASE NOTE:
All Players and Parents / Carers are required to abide by the Player and League Code of conduct.
These details are available on our website:
hhtp://www.monbulkjfc.com.au/the-club/codes-of-conduct
Confidential - Medical Details
CHILD’s NAME: …………………………………………………………….……………….
FAMILY DOCTOR: Name: ………………………………………………Telephone: …………………….…………
Please be aware that if an ambulance is required to take your child to hospital and you
are not at the game at the time, every effort will be made to contact you by phone
before this decision is finalised.
However, if we are unable to contact you, and your child is taken in an ambulance, there
will be a cost incurred if you don't have ambulance cover.
Do you have current Ambulance Cover?
YES / NO
Any Medical Conditions or past relevant injuries (e.g. diabetes, asthma, allergies requiring Epipen etc)
……………………………………………………………………………………………………..………………………………………….
……………………………………………………………………………………………………………………………….……...………..
Medication: ……………………………………………………………………………………………………..………………………..
Medication, if required at the game, will need to be in a well labeled container or bag and
supplied to the team trainer on game day.
DECLARATION:
I, …………………………………………….…
(Parent / Guardian name, Please Print)
hereby consent to my child: ...…………………………………..……..representing the Monbulk Junior Football Club Inc. and I
give consent in case of accident or injury to my Child, where I am not able to be contacted, to the Club arranging such
medical treatment as deemed necessary.
Signed: ………………………..……………………
Date: …………….……………..
Volunteers assisting with MJFC must hold a current Working with Children’s Check.
Do you have a current WORKING WITH CHILDREN’S CHECK CERTIFICATE?
Name:
Yes…………
No …………..
Card No: ……………………. Expiry Date: ……………….
For payment of annual Registrations’: Please ensure your Family name is included with transfer details
Monbulk Junior Football Club – Banking Details: Bendigo Bank Monbulk BSB 633 000 Account No.139252795