ADDRESS:…………………………………………………………………………………………….

SUBURB/TOWN:…………………………………………. POSTCODE:…………………...

HOME PHONE NO. ……………………… BUSINESS HOURS PH NO…………………..….

E- MAIL ADDRESS :………………………………………… AGE GROUP:..…………………

DATE OF BIRTH: ……/……./…….. DATE OF BIRTH VERIFIED? YES/NO

WERE YOU REGISTERED WITH A CLUB LAST YEAR? YES/NO

IF YES, WITH WHAT CLUB? ………………………………………….

I agree to abide by the rules and conditions as laid down by the Q.J.C.A. Inc and affiliated bodies. I also understand that by registering with the Q.J.C.A. Inc. I am automatically in the Q.J.C.A. Inc. compulsory insurance scheme.

PARENTS NAME (Please Print) ………………………………………………….

SIGNED : Player ………………………………….

Parent/Guardian ………………………………….

DATE : ……./……/20…...