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* Date Format: DD slash MM slash YYYY Date of BirthGender* 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 DetailsDate of last tetanus vaccination*Will the player require medication during the camp?*SelectYesNoDetails of medicationDietary Requirements*Please provide any further information you feel will be of assistance:Kit Sizes - Please advise if the kit from Country Camp was the correct size or if you wish to make a change.*SelectCorrect size was providedWould like to changeChanges to Kit Size Shirt Shorts Socks Passport - Do they have a current passport?*SelectYesNo - please organise a passport as soon as possible and provide copy.Your son/daughter will need greater than six months validity on their passport to be able to travel overseas. Passport details*In addition, please either email or text a copy of the passport to Tanya Kruck via mobile 0411 695 537 or email - tanya.kruck@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