AUSTRALIAN FOOTBALL
SUMMER SKILLS CLINIC

Keith Wallis
"Lombardi House"
86 Goldsborough Rd
Taringa, Qld, 4068
Ph: (07) 33784661

REGISTRATION FORM

   

 

First Name:

 

Last Name:

 

Address:

 

Email Address:

 

Phone No:

 

Date of Birth:

 

Club:

 

Playing experience

years

 

Mother's Name

 

Father's Name

 

   

  Representative Teams: (a)
    (b)
    (c)
    (d)
    (e)
    (f)
    (g)
    (h)
 

   

  Club Trophies: 1. 7.
    2. 8.
    3. 9.
    4. 10.
    5. 11.
    6. 12.
 

   

  Other Trophies / Awards: