Singa Cup / Phuket Cup Registration

The WA Country State Team is proudly supported by Gold Fields.
Full Name (as shown on passport)*
First Name Middle Name Last Name
Date of Birth*
DD slash MM slash YYYY

Date of Birth
Gender*
- Male
- Female
Emergency Contact*
Name Email Mobile
Medical – does the player suffer from the following:*
- Respiratory Problems
- Diabetes
- Headaches/Migraies
- Skin Problem
- High Blood Pressure
- Epilepsy
- Eye/Ear problem
- Emotional lllness
- Asthma/Bronchitis
- Allergies (mild – severe)
- Digestive Disorder
- Other
- Not Applicable
Medical Details (if applicable)

If your son/daughter has a medical plan please provide a copy.
Medicare Details*
Private Health Insurance Details
Date of last tetanus vaccination*
Will the player require medication during the tournament?*
Details of medication
Dietary Requirements*
Please provide any further information you feel will be of assistance:
Passport – Do they have a current passport?*
Your son/daughter will need greater than six months validity on their passport to be able to travel overseas.
Passport details*

In addition, please email a copy of the passport to Alex Novatsis alex.novatsis@footballwest.com.au.
I hereby confirm that all information provided above is true and correct and give my consent for the player named above to attend the event and for Football West to seek and authorise medical or other assistance as may be required.
Name*
Parent/Guardian Name Date