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 ……/……/……..