Phoenix Lacrosse Club

Have they received KidSport funding before?
How did you hear about KidSport? ______________________
What sport would the applicant like to play?
_________________________________________________
What club would the applicant like to join?
_________________________________________________
PARENT/GUARDIAN DETAILS
(Privacy disclaimer: All information collected can be used only in matters relating to KidSport)
Name: ___________________________________________
Address: _________________________________________
________________________ Postcode: __ __ __ __
Mobile: __ __ __ __ __ __ __ __ __ __
Home: ( __ __ ) __ __ __ __ __ __ __ __
Email: _________________________________________
Signature: ________________________________________
Yes . No .
Yes . No .
Yes . No .
Yes . No .
Yes . No .
Please attach a copy of your Health Care Card
or Pension Concession Card.
FOR OFFICE USE ONLY
(referral agent)
Name of organisation:
_______________________________________________
Contact person:
_______________________________________________
Contact phone number:
_______________________________________________
Signature:
_______________________________________________
Tick which is applicable:
. Sighted Health Care Card or Pension Concession Card
. Other
(Please note local government/shire may contact you for further clarification)
Return voucher to: Referral agent .
Parent/guardian .
FOR OFFICE USE ONLY
(local government)
. Voucher validated
. Recipient register updated
. Returned to referral agent or applicant
Signature: ______________________________________
Date: ____ /____ /________
Invoiced by the club on: ____ /____ /________