Player Membership Form
Section 1 – Personal Details
Full Name
..................................................................................................................................
Address
..................................................................................................................................
..........................................................................................
Phone: Home .................................
Work
..................................
P/Code…....................
Fax ...........................
Email
..................................................................................................................................
Occupation
.....................................................................................
DOB............................
Previous Club & Association
.......................................................................................................
Ambulance Cover
Yes/No
Next of Kin
Partner ..............................................................
.......... Phone ................................
Father ....................................... .......... Mother ......................... .......... Phone ................................
Section 2 – Skills/Assistance
Skill that you, your parents or partner can bring to the FDCC and assist the Club in kind eg electrician
1 ......................................................................
2 ....................................................................
Section 3 – Payment Method (Circle applicable)
Senior
$360.00
Under 19 as at 1 September
1
Cash/Cheque (payable to Fitzroy Doncaster Cricket Club)
2
Eftpos
from
Cheque/Savings
3
Credit Card
Visa/Mastercard
Name on Card
Card Number
Expiry Date
$270.00
..................................................................................................................
--- Security Code 
/
Amount $
Section 4 – Privacy and Signature
1
2
3
FDCC is committed to the protection of your personal information and will not usually disclose personal information to any other organization or person unless there is a
legal requirement to do so.
If Credit Card details are provided you give FDCC authority to debit your card for the amount of your membership.
As a member the Fitzroy Doncaster Cricket Club, I agree to be bound by the rules as set out in the constitution
Signature
.............................................................................
Date
...../...../........
Player Medical Profile – Personal Record
All information on this sheet is confidential.
Personal Details
Full Name
………………………………… ……........…..……….………………….......................
Blood Group
……………………. Do you object to transfusions?
Yes/No
Healthcare Details
Medicare Number

Private Health
Yes/No
If yes, Name of Fund
……………………………………...
Current History
Current medical Problems
…………………………………………………………………………
……………………………………………………………………………………………………………
Regular Medication including supplements, stating name and dosage
……………………………..
……………………………………………………………………………………………………………
Allergies
…………………………………………………………………………………………..
Sports Injuries (current/recurring or requires surgery)
………………………………………………
Past History
Have you had…
Epilepsy
Diabetes
Heart Problem
Heart Murmur
Asthma/Bronchitis
Hernia
Concussion
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Do you wear…
Have you sustained..
Glasses
Yes/No
Contact Lenses
Soft
Yes/No
Hard Yes/No
A fracture in last 3years
Yes/No if so where ………..
A dislocation Yes/No
is yes, where ………………
Recurring pain in joints or
muscle with play/practice?
Yes/No if so where………...
Have you ever been treated for head, neck or spinal injury?
Yes/No
Details …………………………………………………………………………………………………...
Does this condition affect your performance?
Yes/No
How? …………………………………………………………………………………………………...
To the best of my knowledge, all information contained on this sheet is correct.
(if under 18 please have parent or legal guardian sign)
Signature
………………………………………………………
Date
……/……/……..