2017 DIOCESAN SECONDARY RUGBY LEAGUE OPEN AND U15'S TRIALS
CONSENT/MEDICAL/CONTACT/PLAYER PROFILE/INFORMATION FORM
This compulsory registration process is only for those players who would like to be considered to attend the above trials at Woodlawn College, Lismore on 21st March 2017 (back up date 28th March 2017). The player profile section of this form will be used mainly to enable convener and selectors to place each participant so that they can best showcase their skills.

If your child is selected to attend these trials and is successful in being selected in the Lismore Diocesan Open or U15s team, he will participate at the NSW CCC Northern Country Rugby League Selections to be held at Smithtown on Wednesday 5th April 2017. For these trials you will be required to organise your own travel and accommodation.

Please complete by Thursday 16th February 2017, print a copy if you wish, then press SUBMIT (found at the bottom of this form).

Please complete all questions (type N/A where not applicable)

Players First Name *
Your answer
Players Surname *
Your answer
Gender *
Date of Birth *
Date of birth expressed as dd/mm/yyyy (not 2016)
MM
/
DD
/
YYYY
Age Your Child Turns This Year (2017) *
Sport *
Click on Rugby League below
Required
School *
Schools are arranged in alphabetical order according to town.
Medicare Number *
Your answer
Health Fund Name *
Your answer
Health Fund Number *
Your answer
Medical Information *
Please note here any medical/health information of which managers should be made aware e.g. allergies, dietary restrictions, medication, puffer, epipen, etc . Please type N/A if none.
Your answer
Parent First Name *
Your answer
Parent Surname *
Your answer
Parent Home Phone *
Your answer
Parent Mobile *
Your answer
Parent Email
Your answer
School Representation Rugby League History (Primary School) *
Please tick all the CORRECT boxes. You must have actually played for the team you are ticking, not just attended the selection trial for it. (We will check).
Required
School Representation History (Secondary School) *
Please tick all the CORRECT boxes. You must have actually played for the team you are ticking, not just attended the selection trial for it.
Required
Representation *
Group 1
Group 2
Group 3
Group 18
Under 13s
Under 14s
Under 15s
Under 16s
Under 18s
(18s Only) Did you represent North Coast Under 18s in 2016? *
Required
Representation Gold Coast Titans or Newcastle Knights *
Click in the boxes for each comp in which you have played
Required
Any Other Representation/Other Comments? *
Please list below any other rugby league representation. Please be brief and use point form (not sentences) but this section is an opportunity in particular for any player who has moved from another area to the North Coast.
Your answer
Preferred Playing Position 1 *
Your answer
Preferred Playing Position 2 *
Your answer
Preferred Playing Position 3 *
Your answer
Commitment *
Please click Yes to indicate that your child is also available and committed, if selected at Woodlawn, to attend Northern CCC Trials on 5th April and CCC Trials on 19th and 20th May 2017.
Codes of Conduct *
Click Yes if player and parents have read and will abide by their respective codes of conduct at these trials and that you understand and accept that your child is to behave in an appropriate manner and have explained this obligation to him/her. Clicking Yes also indicates that you are aware that if your son/daughter seriously contravenes behavioural expectations, he/she may be immediately excluded from the trial. Should this eventuate, you accept full responsibility for your son/daughter upon notification of his/her exclusion by the convener. Yes also indicates that you are aware that the child’s school may take disciplinary action after this event and that future Diocesan sports representation may be in jeopardy.
Consent *
I hereby consent to my son/daughter participating in Diocesan Secondary Rugby League Trials. I understand that transport to and from the venue and accommodation is a parent/guardian responsibility. In the event of accident or illness I authorise the obtaining on my behalf of any such medical assistance that may benefit my child. I accept responsibility and expenses incurred. Please note that your child's school and/or zone might also require written consent for this activity.
Submit
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