SOUTH AUSTRALIAN LITTLE ATHLETICS ASSOCIATION SQUAD LA REGISTRATION FORM Name: Address: Suburb:
Post Code:
Phone No. Home:
Mobile:
Email: Sex:
Date of Birth:
Male
Female
Centre: Emergency Contact Person: Relation to Athlete:
Phone No:
Medical: I confirm that the above information is true and correct, and allow it to be used by the South Australian Little Athletics Association in accordance with all Privacy and Confidentiality Policies. By completing this form and agreeing to this declaration, I allow my child to participate in the 2014/15 Squad LA development program. Date:
Parent/Guardian:
PAYMENT DETAILS $
Direct Deposit ( )
Cheque ( )
Cash ( )
Money Order ( )
Note: Please include a reference if paid by Direct Deposit Application and Payment to be returned by Friday 18th July 2014
