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2024-06-13T21:44:59+12:00
WRLA July School Holiday Clinic
WRLA July School Holiday Clinic
1
Personal Details
2
Contact Details
3
Medical
Personal Details
Name
(Required)
First
Last
Preferred Name (if applicable)
Date of Birth
(Required)
DD slash MM slash YYYY
Please remember that your child has to be born from 2011 or later. 13 years or older.
Gender
(Required)
Male
Female
Ethnicity
(Required)
Please Select
Maori
NZ European
Pacific Islander
Asian
Other
Primary Position
(Required)
Fullback
Winger
Centre
Standoff (No.6)
Halfback
Prop
Hooker
Second Rower
Lock (No.13)
Secondary Position
(Required)
Fullback
Winger
Centre
Standoff (No.6)
Halfback
Prop
Hooker
Second Rower
Lock (No.13)
Age Grade
(Required)
Club
(Required)
Bay Roskill Vikings
East Coast Barracudas
Ellerslie Eagles
Glenfield Greyhounds
Glenora Bears
Hibiscus Coast Raiders
Howick Hornets
Mangere East Hawks
Manukau Magpies
Manurewa Marlins
Marist Saints
Mt Albert Lions
Mt Wellington Warriors
Northcote Tigers
New Lynn Stags
Otahuhu Leopards
Otara Scorpions
Pakuranga Jaguars
Papakura Sea Eagles
Papatoetoe Panthers
Pt Chevalier Pirates
Ponsonby Ponies
Pukekohe Pythons
Richmond Bulldogs
Te Atatu Roosters
Tuakau Broncos
Waiheke Rams
Waitemata Seagulls
Other
Contact Details
Primary Phone Number / Mobile
(Required)
Secondary Phone Number / Home
Address
(Required)
Street Address
Suburb
City
ZIP / Postal Code
Email
(Required)
Emergency Contact
Emergency Contact Name
(Required)
First
Last
Emergency Contact Phone Number
(Required)
Medical
Do you have any medical conditions?
(Required)
No
Yes
Please detail your medical conditions
(Required)
Consent
I agree to the privacy policy.
I give permission for my name and image (or the registering individual's name and image if I am completing this registration on the behalf of a minor) to appear on the Club's website and on other social media or networking websites utilised by the Club including, without limitation, Facebook and Twitter. This includes organisations who we are assisting with tournaments and promotions. (For the avoidance of doubt, the registered individual's other personal information will not appear on the Club's website or on other social media or networking websites utilised by the Club and will otherwise be dealt with in accordance with the Privacy Act.
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