NYC Coffs Harbour 2022 Player Information Name(Required) First Last Date of Birth MM slash DD slash YYYY Representative Team(Required)State Team Girls Under 14'sState Team Girls Under 16'sState Team Boys Under 14's (Perth Glory)State Team Boys Under 15's (Perth Glory)State Team Boys Under 14's (Football West)State Team Boys Under 15's (Football West)Emergency Contact 1 Emergency Contact 2 Emergency Contact Email 1 Emergency Contact Email 2 Emergency Contact Phone 1 Emergency Contact Phone 2 Will a Parent/Guardian be attending the tournament? Yes No Name of Parent/Guardian 1 First Last Parent/Guardian Phone NumberHeadaches / Migraine(Required) Yes No Asthma / Bronchitis(Required) Yes No Allergies(Required) Yes No Type of Allergies Medical Details(Required) Yes No Medical information Name on Medicare Card Position (IRN)Medicare NumberPrivate Health Insurance Provider Position (IRN)Member NumberDate of Last Tetanus Vaccination Will the player require medication during the trip? Yes No Details of MedicationDietary RequirementsPlease provide any further info you feel will be of assistance