Gold Coast Kaufana Registration Details

Participant Details

First Name *

Middle Name

Last Name *

2nd Preferred Position *

Date of Birth *

Gender *

Age/Grade *

Email Address *

Participant Mobile

1st Preferred Position *

Current Address *

Street address *

City *

State *

Postcode *

Participant Proof of ID (Brith Certificate or Passport) *

Browse

Participant Photo ID (Passport like photo) *

Browse

Parent/ Guardian Details

Parent/ Guardian Full Name

Parent/ Guardian Email

Parent/ Guardian Mobile

Occupationtype n/a if you do not wish to share this info

Emergency Contact

Emergency Contact Full Name *

Emergency Contact Email

Emergency Contact Mobile *

Heritage / Qualifications to play for QLD Tonga Rugby League

Country of Birth *

Villages (at least 2) *

Fathers Heritage

Mothers Heritage

Grand Fathers Heritage (Fathers side) *

Grand Fathers Heritage (Mothers side) *

Grand Mothers Heritage (Fathers side) *

Grand Mothers Heritage (Mothers side) *

Have you played Rugby League before? *

If YES please complete the below section in Full.

Age/ Grade

Club Name:

Positions Played

Medical Information

Please List any known Medical Conditions *Diabetes, Asthma etc

Allergies? *Food, medication and/or environmental? Type n/a if this does not apply to you.

Have you had any concussions in the last 12 months? *

If Yes please specify

Have you had any Surgeries in the last 12 months? *

If Yes please provide surgery type and dates

Parent / Guardian Medical Waiver *

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I understand and agree to the following: My records / My Childs records and information are true and accurate. In case of emergency, my child / the participant may be transported to Emergency Medical Services to a hospital and provided treatment, and I am responsible for charges related to the transportation and medical treatment.

Medical Declaration Date Acknowledged *

Acknowledgement

I, the undersigned agree to participate in the Queensland Tonga Rugby League Inc sactioned activities on my own accord and agree to the zone season fee of $155.

I, the undersignee understand a non-refundable deposit of $25 in all circumstances to secure their spot in the team, including but not limited to if participant decides not to play. The deposit shall be made to Queensland Tonga Rugby League Inc and is paid towards Resources and Insurance.

Remainder of $130 registration fee and expenses are to be paid by the player directly to their designated zone.

By signing this I declare that the above information is true and correct and I understand that the same will be added to the Queensland Tonga Rugby League Inc database.

**Disclosure - Queensland Tonga Rugby League Inc provides a positive junior rugby league experience for children aged 6 to Opens. All tournaments are fully insured by and sanctioned.

I allow my/my child's photo to be used by Queensland Tonga Rugby League and/or QTRL Zones (Lomipeau, Kau Toa, Stallions) and acknowledge all rights in the promotional material are owned by the QTRL and/or QTRL Zones.

I would like you to send me and my parent/guardian information (from any of the QTRL Zones) regarding rugby league events, activities and offers and consent to the use of my personal information in the manner.

I would like to receive a separate Direct Debit form to acknowledge prior to the deduction of the remaining $130 zone fee.

Signature *

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Date Signed *

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