Membership Renewal Form

Norah Head Panthers Hockey Club

Registration Form 2014
- Full Name
  
  First NameMiddle NameLast Name
- Date of Birth
  
  DayMonthYear
- Age at 1 Jan 2014
  Juniors Only
- Gender
- Parent/ Guardian Names
- Address
- Suburb
- Post Code
- State
- E-mail
- Home Phone
- Mobile Number
- Work Phone
- Team (s) in 2013
- Preferred Teams for 2013
  Please note that there are Team Selections for
  the Senior divisions and the player may not be
  selected in their preferred team.
- Juniors
- Senior Women
- Senior Men
- Clearance Details
  If played with another club in the last 3 years
- Medical Details
- Medicare Number
- Person to contact in case of emergency:
  Parent/Guardian
- Relationship
  ex. Father, Mother, etc.
- Contact details of person to contact in case of emergency
- Medical notes
- PLEASE NOTE:
  Although this form can be completed online the Player, Parent/Guardian must sign a copy of this form. Please speak to your relative Team Manager for a printed copy of this form.
- Code of Conduct
- IMPORTANT:
  As a member of Norah Head Panthers Hockey Club, I agree to honour my financial committment to the club and to abide by the NSW Association's Code of Conduct.
- Please type "I Agree"
- Enter the words shown:
- www.norahheadpanthers.org.au
  norahheadpanthers@gmail.com
- Should be Empty: