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Heath Park Rangers Registration Form

FULL NAME:


DATE OF BIRTH:

 

ADDRESS:  _____________________________________________________________________________

                  _____________________________________________________________________________

 

CONTACT DETAILS:

     HOME:  __________________  MOBILE:__________________   OTHER: ____________________

     E-MAIL:____________________

 

MEDICAL CONDITIONS / ALLERGIES: e.g Asthma etc.

__________________________________________________________________________

__________________________________________________________________________


EMERGENCY CONTACT: 1ST                                      EMERGENCY CONTACT: 2ND                                                               

NAME:      __________________________       NAME:     __________________________  

ADDRESS:__________________________       ADDRESS:__________________________ 

                 __________________________                       __________________________

                 __________________________                       __________________________        

TEL:          __________________________          TEL:       __________________________


SIGNATURE OF PARENT / GUARDIAN: ________________________________________________

                                                      DATE:______________________

INFORMATION NEEDED TO BE RETURNED WITH FORM:

  1. ORIGINAL BIRTH CERTIFICATE (WILL BE RETURNED A.S.A.P)
  2. 3 PASSPORT PHOTO’S (NAME OF CHILD TO BE PRINTED ON REVERSE).
  3. COMPLETED BANK MANDATE FORM.    
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