Little Athletics Registration Form
Little Athletics Western Australia Terms and Conditions
By signing this form I agree to the Little Athletics Western Australia Terms & Conditions of Membership. Terms and Conditions are available at registration. Signed ______
Child / Member Details
Surname
/First Name
/Age
/ DOB (dd/mm/yyyy) /o F o M
School
/Medical Information
/Permission to Seek Medical Treatment
/Do You Have Ambulance Cover?
o Yes o No
/o Yes o No
Office Use Only
Rego Number
/Proof of Age
o Yes o No /Club
/Reg last season?
o Yes o NoIf you would like to register more children please use a separate registration form, complete the top section only and attach to this form.
Family Details
Please provide the name and contact details of your Family. These details will be used by your Centre to send out reminders about upcoming events and duty rosters. This also includes login details for ResultsHQ.
Username: Password
Primary Contact / Guardian
/ /First Name
/Surname
/ /Occupation
/ /Mobile (or l/line)
/ /Secondary Contact / Guardian
/ /First Name
/Surname
/ /Occupation
/ /Mobile (or l/line)
/ /Street Address
/ / / / /Suburb
/ /State & Postcode
Is the member of aboriginal or Torres Strait Islander origin:
Please cross (X) o Yes o No
Please answer the following questions:
How did you hear about Little Athletics? ______
Have you participated in a Little Athletics run school clinic (LAPS) ? Yes / No
Have you seen Centre / Club promotions, incl. open days, posters, flyers etc.? Yes / No
Have you visited the Little Athletics websi9te or seen us on Facebook? Yes / No
Do you have a Kidsport voucher? Yes / No
Office Use Only
Entered into ResultsHQ
/ o Yes /Any Relevant Notes
Payment Received
/ o Yes o No /Any Relevant Notes
Proof of Age Ticked
/ o Yes /Any Relevant Notes
Status Manager Approved
/ o Yes /Any Relevant Notes
Rego Number Assigned
/ o Yes /Any Relevant Notes