REGISTER TODAY

Roma & District Junior Soccer Association

Registration Form

If you have a Play On Voucher please click the button below to be taken to a different Registration Form.

Player/s details

Date of Birth - Child 1

Day

Month

Year

Date of Birth - Child 2

Day

Month

Year

Date of Birth - Child 3

Day

Month

Year

Date of Birth - Child 4

Day

Month

Year

Phone

Parent/Guardian Name

Phone

Parent/Guardian Name

Phone

Address

Country/Region

Address

City

Zip / Postal code

Emergency Contact Information

Name

Relationship?

Name

Relationship?

Phone

Address

Country/Region

Address

City

Zip / Postal code

By signing and paying for registration, you acknowledge and agree to abide by the rules and directions given by the Roma & District Junior Soccer Association Office Bearers, Members and Referee’s.

I agree & acknowledge

Medical Information

I hereby consent to the provision of the following health information for Roma and District Junior Soccer Association’s records and to use in the event of injury, illness or emergency, if required.

Medicare Number

Ref Number

Expiry Date

Day

Month

Year

Medicare Number

Ref Number

Expiry Date

Day

Month

Year

Private Health Insurance Name:

Private Health Card Number

Exisiting medical conditions/injuries/allergies

Regular medication/requirements

Consent:

I would like to be added to the emailing list to keep up to date with events

I consent for the information provided to be stored in Roma and District Junior Soccer Association records.

I consent for photos of my child (if under 18) to be posted on social media for the purpose of advertising or promoting Roma and District Junior Soccer Association.

Volunteering:

Roma District Junior Soccer Association relies on volunteers to ensure continuing progress of junior soccer. If you can assist in any manner, please contact the secretary to nominate your interest.

I would like to be contacted with more information about volunteering.

Registration Payment

U9 and above$80

U6$60

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

For further enquiries please feel free to email the Secretary at romajuniorsoccer@gmail.com

Play On Voucher Registration

Registering more than one player? You can adjust the quantity at checkout.

GET IN TOUCH

Have questions or need more information? Feel free to contact Roma Junior Soccer. We're here to support our players and families on their soccer journey.

Tel: 0417 032 216 Email: romajuniorsoccer@gmail.com

Contact