Junior Registration Participating Teams: Under 10, 12, 14Please complete Parents Survey after this form Name*FirstLast Address* Street Address City State / Province / Region Postal / Zip Code AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongoCongo (Brazzaville)Costa RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth MacedoniaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWalesYemenZambiaZimbabwe Country Phone Email* Date of Birth*01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 20192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year JUNIOR INFORMATION - If not previously registered - please upload a copy of the child's birth certificate or email a copy of the child's birth certificate to MEDICAL RECORD AND AUTHORISATION: Has your child ever suffered from*EpilepsyDiabeticAsthmaAllergy *Other NONE Allergy/Other * Any other conditions that we may need to know When did your child last receive a Tetanus Injection ?* Name & Health Fund Member Number (if any) Emergency Contact Person*FirstLast Emergency Contact Phone JUNIOR INFORMATION: PARENT / GUARDIAN Being the parent/guardian of the above mentioned hereby consent to him/her to be registered with the Keilor Park Cricket Club and to participate in any or all activities associated with the club. I authorize any club photography of myself and or child to be used in club communications and social media programs. Consent is further given in the event of injury or illness sustained where it is impracticable to communicate with me for the administration of such medical or surgical treatment as may be deemed necessary. N.B. The cost of Ambulance use is at the player’s own expense. PLEASE TYPE YOUR NAME BELOW* PLEASE ACKNOWLEDGE: I agree to be bound by any Code of Behaviour and Policies of Keilor Park Cricket Club for the time being in force, including Australian Cricket's "Looking After Our Kids" Code of Behaviour for Affiliated Associations and Clubs.Agree PAYMENT INFO: (All fees include GST) EFT: Keilor Park Cricket Club Division*JuniorsWoolworths Blast SOCIAL MEDIA: The information provided below may be used to inform players (or parents) about news, training, events or sponsor offers.Agree Instagram Account - if more than one account please add@ @ @ Facebook Account - if more than one account please add - Insert URLhttps://www.facebook.com/ https://www.facebook.com/ https://www.facebook.com/Send a copy of this message to yourself reCAPTCHASubmitReset