|
SURNAME |
|
|
FIRST NAME |
|
|
DATE OF BIRTH |
|
|
|
|
|
PARTICIPATING IN 2010(PLEASE CIRCLE) |
DANCE GYMNASTICS |
|
CHP RSL CLUB MEMBER NAME |
|
|
CHP RSL CLUB MEMBERSHIP NUMBER |
|
|
CARD SIGHTED ( COMMITTEE USE ONLY) |
|
|
ADDRESS DETAILS STREET NO:
SUBURB |
STREET NAME
POSTCODE |
|
GUARDIAN 1 NAME
|
HOME / MOBILE PHONE
|
|
GUARDIAN 2 NAME
|
HOME / MOBILE PHONE
|
|
EMERGENCY CONTACT NAME / RELATIONSHIP
|
HOME / MOBILE PHONE
|
|
Member’s Health Does your child suffer from Asthma? Please circle Yes / No If yes, please give details of Asthma plan.
|
Other health concerns / allergies etc. Please circle Yes / No If yes, please give details.
|
