Altona Little Athletics Centre Registration Form 2012/2013
PAID $_______________
Receipt No: __________________
Where did you hear about Little Athletics? Re-Reg Friends Paper Radio TV Leaflet School Other
Child No 1 Surname:
Given Names:
DOB:
Address:
Gender: Male Female Any Asthma/Allergies/Disabilities/Medical Problems/Long Term Medication? No Yes, please specify: Age Group: U B / G
Do you Authorise medical treatment Y/ N Are you an Ambulance member Y/N
REGO NO:
Centre Use Only: Type of Rego: NEW / RE / TRANSFER Proof of Age sighted: YES / NO Date of Registration: _____/_____/______
Child No 2 Surname:
Given Names:
DOB:
Address:
Gender: Male Female Any Asthma/Allergies/Disabilities/Medical Problems/Long Term Medication? No Yes, please specify: Age Group: U B / G
Do you Authorise medical treatment Y/N
Are you an ambulance member Y / N REGO NO:
Centre Use Only: Type of Rego: NEW / RE / TRANSFER Proof of Age sighted: YES / NO Date of Registration: _____/_____/______
Family Information: Parents/Guardians named below are Members of the Centre and are entitled to participate in its management activities.
Mother/Guardian Surname:
First Name:
Occupation:
Contact Address:
Postcode:
Phone:
Mobile:
Email:
Do you have any coaching or officiating qualifications: Yes No If Yes, what level?
What areas?
Are you interested in becoming a coach or official? Yes No Do you have first aid training? Yes No
In what areas of the Centre are you prepared to assist in (no qualifications necessary)?
Coaching Officials Canteen Age Marshall Other, please specify:
Do you have a Working
with Children Card? Yes No If Yes, Card No:
Sighted: Expiry Date:
Father/Guardian Surname:
First Name:
Occupation:
Contact Address:
Postcode:
Phone:
Mobile:
Email:
Do you have any coaching or officiating qualifications: Yes No If Yes, what level?
What areas?
Are you interested in becoming a coach or official? Yes No Do you have first aid training? Yes No
In what areas of the Centre are you prepared to assist in (no qualifications necessary)?
Coaching Officials Canteen Age Marshall Other, please specify:
Do you have a Working
With Children Card? Yes No If Yes, Card No:
Sighted: Expiry Date:
Alternative Emergency Contact: Name:
Phone No:
Relationship to Child:
Privacy & Parent/Guardian Declaration:
The Victorian Little Athletics Association Inc (LAVIC) is committed to the privacy of its members. You have the right to access personal information the Association holds concerning you or your child/children, and to request correction of any errors in it. I/We will ensure I/We receive the Parent Information Handbook which outlines policies under which Little Athletics is governed.
I/We consent, unless I/We otherwise advise in writing to VLAA, to the use of my/our child/children’s details including name, and also image and likeness, before, during or after the season for promotional, broadcasting or reporting purposes in any media. As parent(s)/guardian(s) of the above named athlete/s, I/We hereby acknowledge the above and verify that all details on this form are true and correct.
I/We consent, unless I/We otherwise advise in writing to VLAA, to Any medical information provided be kept on file by this Centre and SALAA; and I / we give Permission for VLAA to seek emergency medical treatment if required and administer as
We hereby apply for membership of the Association as Ordinary Members. In the event of my/our admission I/We agree to abide by the Rules, Regulations, Codes of behavior, Guidelines and Directives as they pertain to Ordinary members.
Parent/Guardian Signature:……….………
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LETICS CENTREt
ALTONA LITT
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LETICS CENTREt
