After School Programme Registration Form

This form is to be completed by the parent or caregiver. Once we receive your form, we will contact you.
Please note:
All information provided will remain confidential.
Young person refers to anyone aged 5-21 years old.
* indicates a required field
Registration
Please select the choice of sport you want to register for:*
- Bowling
- Cricket
- Football
- Hockey
- Rowing
- Touch Rugby
Participant Details
Name of participant*
First Last
Name of parent or caregiver*
Address*
Street Address Address Line 2 City ZIP / Postal Code
Phone*
Email*
Age*

The programme is only open for young people aged 5-21 years old.
Date of birth*

Day
Month
Year
Tell us a little about the participant's impairment and how we can support them.

If you prefer, we can talk about this.
Medical requirements

Tell us about anything we need to know.
School or service*
Current sporting interests
Future sporting, fitness or social goals
Other Details
We welcome parent or caregiver involvement. Are you interested?*
- Yes
- No
Photos may be taken and used for promotional purposes. Do you consent?*
- Yes
- No
Emergency contact person*
Emergency contact phone number*
Emergency contact email
Where did you hear about this programme?*
- Word of mouth
- Website
- School or service
- Social media
Any other comments?
Comments
This field is for validation purposes and should be left unchanged.

Check out our online store Mobility Centre

Registration