Southland Age Group
Player Details and Medical Consent
Team *
Player Name *
Your answer
Player Date of Birth *
MM
/
DD
/
YYYY
Parent/Caregiver Name *
Your answer
Parent/Caregiver Address *
Your answer
Parent/Caregiver Phone (Please Provide 2) *
Your answer
Parent/Caregiver Email Address *
Your answer
Emergency Contact Details
Please provide 2 contact names and phone numbers
Contact 1 *
Your answer
Contact 2 *
Your answer
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