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Parent / Carer Details
Name*
First Last
Parent / Carers Contact Number*
Parent / Carers Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
No of Children attending
- 1
- 2
- 3
- 4
Player 1 Details
Is your child a returning player?*
- Yes
- No
Holiday Clinic Date
Name*
First Last
DOB*
Gender*
- Male
- Female
Name of Junior Rugby Club your child plays for
What School does your child attend?
Does your child have any illnesses, allergies or injuries we should know about? Please provide details...*
Player 2 Details
Is your child a returning player?*
- Yes
- No
Holiday Clinic Date
Name*
First Last
DOB*
Gender*
- Male
- Female
Name of Junior Rugby Club your child plays for
What School does your child attend?
Does your child have any illnesses, allergies or injuries we should know about? Please provide details...*
Player 3 Details
Is your child a returning player?*
- Yes
- No
Holiday Clinic Date
Name*
First Last
DOB*
Gender*
- Male
- Female
Name of Junior Rugby Club your child plays for
What School does your child attend?
Does your child have any illnesses, allergies or injuries we should know about? Please provide details...*
Player 4 Details
Is your child a returning player?*
- Yes
- No
Holiday Clinic Date
Name*
First Last
DOB*
Gender*
- Male
- Female
Name of Junior Rugby Club your child plays for
What School does your child attend?
Does your child have any illnesses, allergies or injuries we should know about? Please provide details...*
In an emergency, do you authorise the Southern Cross Rugby to arrange any necessary medical treatment for your child/ren where contact with yourself or nominated contact are unavailable?*
- Yes
- No
How did you hear about Southern Cross Rugby?
*
- Yes, I agree to Terms and Conditions
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