Registration

Firstname

Middle Initial

Surname

Date of Birth

Gender

Mobile

Password

Address

Suburb

State

Postcode

Registering as

Are you an existing member?

If no, list previous Club registered

Registering for

Jumper Number

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Email

Emergency Contact Mobile

Relationship to Member

Medicare Number

Your Position Number on Card

Private Health Insurance

Name of Institution

Membership Number

Your Position Number on Card

Ambulance Cover

Cover Number

Your Position Number on Card

Do you allow AJAX FC to administer medical treatment in case of emergency?

Name of GP

Contact Number of GP

Name of Practice

GP Email

Are you on medication?

Please list medications

Do you have allergies?

Please list your allergies

Please list allergy treatments

Epilepsy

Do you have a known heart condition?

Are you diabetic?

Diabetic type?

Are you insulin dependent?

Do you have/suffer from asthma?

Yes No

Do you have any known physical injuries?

Please list injuries

Please list rehab plan management

Any pre-existing medical conditions or injuries?

Treatment plan management for injuries

Player Position

Debut Year

Games for AJAX FC

Goals 2019

Favourite AJAX FC Memory

Favourite AJAX FC player & why?

Playing/Training Superstitions

Personal Motto

What is your greatest sporting achievement?

AFL Club

Favourite AFL Player

Favourite Food

Dream guests at a dinner party

Height

I have read and understood all the information above to be correct and true.