CDSFA STRIKER SCHOOL PROGRAM
STRIKER SCHOOL MEDICAL & REGISTRATION FORM
Please complete this Registration form and send along with cheque made payable to Canterbury &
District Soccer Football Association c/o CDSFA at PO Box 402 Croydon Pk, NSW 2133 or by
faxing 9716 8559. Registration closes Monday 23rd Sept, 2011.
This course is for 2011 CDSFA Club Registered players ONLY
Please note that faxed registrations will not be confirmed until payment is received.
(EFTPOS and Credit Card facilities are available at CDSFA Office at 42 Arthur Street, Ashfield
(Eastern end of Pratten Park Bowling Club) or via phone: (02) 9716-8558
Or on page 2 of this form
Name___________________________________ D.O.B_________________ Age ______________
CDSFA ID NO._____________ CLUB: ________________________________________________
Phone (H)___________________ (W) __________________ (Mob) _________________________
Tick Session time & Day:
Monday (10/10-28/11) 5:10-6:10
15-7:15
I give permission for my child to attend the CDSFA Striker School Program for the day’s, respective
dates & times ticked above. I authorise the coaches of the Program to act for me, accordingly to their best
judgement, in any emergency requiring medical attention and to call on the services of an ambulance if
needed. I agree to accept responsibility for any costs involved. By signing I hereby acknowledge that my
child is registered with the NSW Football Association.
Parent/Guardian Signature
Parent/Guardian Name
Date
1)
Has your son ever suffered from:
Al lerg ie s
Ye s/ N o
He ar t or l un g c o m pla in t
Ye s/ N o
Dia be te s
Ye s/ N o
E pi le psy
Ye s/ N o
A st h ma
Ye s/ N o
Ot her
Ye s/ N o
Details: ______________________________________________________________________________
_____________________________________________________________________________________
2)
Is your child taking any DRUG or MEDICATION or under any type of TREATMENT or have any
CONDITION which may prevent full involvement in the programme? If yes please give details or attach
note. (e.g. Ventolin for Asthma. N.B. Asthmatics should bring a spare puffer)
_____________________________________________________________________________________
3)
Has your child had, or been in contact with, any infectious diseases (including the normal childhood diseases)
in the past three months? If YES please give details or attach note.
_____________________________________________________________________________________
4)
Does your child have any special dietary/food requirement? If so please give details (This does not include
foods which are disliked)
____________________________________________________________________________________
1 Striker School Registration Form| CDSFA & Trinity Grammar School
PRI M A R Y CO NT A C T PER S ON – parent of guardian contact details
Name: ______________________________ Relationship to Player: ____________________________
Contact Nos (H) __________________ (W) ____________________ (Mob) ______________________
SE CO ND A R Y CO NT A CT P E R SO N – parent of guardian contact details
Name: ______________________________ Relationship to Player: ____________________________
Contact Nos (H) __________________ (W) ____________________ (Mob) ______________________
Credit Card and EFTPOS facility available:

Cheque;

Master Card;

Visa (Tick appropriate)
Full Name of Cardholder (as it appears on card): _____________________________________________
Card No. ___________ / ___________ / ___________ / ___________
Expiry Date: ______ / ______
Confirmation Code: __________ (last 3 digits on back of card - if applicable)
Date: ____/____/____
Amount: $__________._____
Signature of Cardholder:________________________________
2 Striker School Registration Form| CDSFA & Trinity Grammar School