PRO SKILLS MEDICAL CONSENT FORM

LAST NAME: _______________________________________

FIRST NAME: _______________________________________

DATE OF BIRTH: Day/Month/Year _____/_____/_____

ADDRESS: (NO P.O. Box addresses)

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EMAIL ADDRESS:....................................................@...............................................

GENDER M / F (circle one)

Contact Number: ________________________

MEDICAL CONDITIONS:_____________________________________________________

GP:_______________________________________________________________________

PLAYER REGISTRATION DECLARATION:
I hereby declare
(a) I am not under suspension by any sporting organisation.
(b) I am duly qualified to play for the team I have listed according to the rules
of the Association.
(c) I will inform pro skills soccer of any change to the above details.
I hereby declare that all the information submitted on this form is correct.
(Parent/Guardian accepts responsibility on behalf of a minor).

DECLARATION (Approval - Photographic or Film Image)
I agree to Pro Skills using my name and image in the promotion and marketing of Pro Skills, the programs that are conducted and the commercial relationships that are entered into in connection with those programs.

PARTICIPANT APPROVAL or PARENT/GUARDIAN APPROVAL (if participant is under 18):
Signed: …………………………….. Name: …………………………Date: ……./……./......