2023 Country Camp – Participant Registration This registration form is for players invited to participate in the 2023 Country Camp. Please complete all fields to confirm acceptance of your invitation for 2023.Online registrations will close at 5:00pm, Friday 10th February 2023. Player detailsPlease enter the player’s details below.Full Name(Required) First Middle Last Date of Birth(Required) DD slash MM slash YYYY Region(Required)— Select —AlbanyBroomeCarnarvonCCJSAEsperanceGeraldtonGoldfieldsHedlandKarrathaKununurraLNJSANewmanPeelTom PriceAge Group(Required)— Select —U12 Girls (2013, 2012, 2011)U14 Girls (2010, 2009)U16 Girls (2008, 2007)U12 Boys (2013, 2012, 2011)U13 Boys (2010)U14 Boys (2009)U15 Boys (2008)U16 Boys (2007)Parent/Guardian detailsPlease enter details of parent or guardian responsible for participant.Parent/Guardian – Name(Required) First Last Parent/Guardian – Email(Required) Parent/Guardian – Mobile(Required)Participant – Medical informationPlease provide details or any relevant medical or dietary information.Does the player suffer from any of the following medical conditions?(Required) No – The player does not suffer from any medical conditions Respiratory Problems Diabetes Headache/Migraines Skin Problems High Blood Pressure Epilepsy Eye/Ear problem Emotional Illness Asthma/Bronchitis Allergies (mild – severe) Digestive Disorder Other (specify below) Please specify medical details(Required)Medicare number(Required) Do you have private health cover?(Required) Yes No Private health – Provider name(Required) Private health – Member number(Required) Will the player require regular medication during camp?(Required) Yes No Please specify details of medication(Required)Date of last tetanus vaccination (if known)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does the player have any special dietary requirements?(Required) Yes No Dietary Requirements(Required)List N/A if not applicable Please include any extra medical or dietary information that may be of assistanceKit sizesPlease select a size for each item of apparel listed below. Please note, as of 2023, Football West has a new apparel partner. Sizing may be different to previous years, so please make sure you check sizing guides before submitting. Please refer to the New Balance sizing guides linked below for assistance with sizing. Jersey(Required)— Select —68101214XSSMLXL2XL3XL4XL5XLSize guide – New Balance JerseyShorts(Required)— Select —68101214XSSMLXL2XL3XL4XL5XLSize guide – New Balance ShortsEmergency contact detailsEmergency contact – Name(Required) First Last Emergency contact – Mobile(Required) Emergency contact – Email(Required) Payment and consentCountry Camp – Deposit (Tester) Price: The deposit of $170 is non-refundable. Total cost of the camp for 2023 is $795 (inclusive of GST). The remaining balance ($625) will be invoiced by Football West after registrations close. Final payment will be due approximately 4 weeks before camp commencement date. Payment details(Required)Card Details Cardholder Name Code of conduct(Required) I agree to the Football West Touring Code of ConductConsent(Required) I hereby confirm that all information provided above is true and correct and give my consent for the player named above to attend the 2023 Country Camp and for Football West to seek and authorise medical or other assistance as may be required.