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Athlete Profile 2014
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Membership Number
Available from Club Secretary
Your answer
Player Date of Birth
*
MM
/
DD
/
YYYY
Player's Address
*
Your answer
Player's Postcode
*
Your answer
Development Squad
*
Under 14
Under 15
Under 16
Under 17
Minor
School
*
St Patrick's Academy Dungannon
St Patrick's College Dungannon
Omagh CBS
St Ciaran's Ballygawley
Holy Trinity Cookstown
St Joseph's Coalisland
St Joseph's Donaghmore
Holy Cross Strabane
Dean Maguirc Carrickmore
St John's Dromore
St Patrick's Grammar Armagh
St Mary's Magherafelt
St Pius X Magherafelt
Other:
Dominant Hand
Right
Left
Clear selection
Dominant Foot
Right
Left
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Doctor's Name
*
Your answer
Doctor's Telephone
*
Your answer
Surname NOK 1
*
Your answer
Forename NOK 1
*
Your answer
Address NOK 1
Your answer
Postcode NOK 1
Your answer
Relationship NOK 1
*
Your answer
Email Address NOK 1
*
Your answer
Mobile NOK 1
*
Your answer
Landline NOK 1
Your answer
Surname NOK 2
Your answer
Forename NOK 2
Your answer
Address NOK 2
Your answer
Postcode NOK 2
Your answer
Relationship NOK 2
Your answer
Email Address NOK 2
Your answer
Mobile NOK 2
Your answer
Landline NOK 2
Your answer
Do you give permission for your son/daughter to receive treatment in an emergency?
*
Yes
No
Permissions: video
*
Yes
No
Permissions: Photographs
*
Yes
No
Injury History: When did it occur? Treatment received? Current status?
Your answer
County
Your answer
Medical History
Condition
Your answer
Medication
Your answer
Allergies
Your answer
Dietary requirement
Your answer
Blood Group
Your answer
Heart Screen
Yes
No
If yes, please give date:
Your answer
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