EmailMeForm
Adult Registration Form
Interest in playing a sport/activity at Samson Recreation Centre
Contact Details
*
First
Last
Contact Number
*
Email
*
Date of birth
*
DD
/
MM
/
YYYY
Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Medical conditions (if no medical conditions write none)
*
Emergency Contact Name
*
Relationship
Emergency Contact Number
*
Sport/activity
*
Please select
Ladies Netball
Seniors Badminton
Yoga
Have you played this/these sport/s before?
*
Please select
Yes
No
If interested in netball, what is your favourite position/s?
If interested in netball, when are you available to play?
Monday evening
Wednesday evening
Thursday morning
Any other information you would like to provide?
I acknowledge that all patrons participate in fitness or sports competitions at their own risk.
*
Please select
yes
Second option
Third option
All of the above information is true and correct as of today. If any of this information changes it is my responsibility to inform Samson Recreation Centre as soon as possible.
*
Please select
Yes
Second option
Third option
Signature of applicant
*
Date Time
DD
/
MM
/
YYYY
