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Subject General EnquiryLane HireCricket ToursPrograms
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Personal Information
Name
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Your birthday*
School Year Level ReceptionYear 1Year 2Year 3Year 4Year 5Year 6Year 7Year 8Year 9Year 10Year 11Year 12
Teams played for
What is your X-Factor?
Please select the skills you'd like to work on
Batting LHRH
Bowling LHRH
Wicket Keeper YesNo
Session Info
Desired Duration 30min45min60min90min
Preferred Days MondayTuesdayWednesdayThursdayFriday
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First & Given Names*
Surname*
Email Address *
School
Year Level ReceptionYear 1Year 2Year 3Year 4Year 5Year 6Year 7Year 8Year 9Year 10Year 11Year 12
Contact Information
Address*
Postcode*
Phone (Home)
Phone (Work)
Phone (Mobile)*
Travel Information (Optional)
Passport Details
Passport Number
Passport Expiry
Frequent Flyer Details
Frequent Flyer Number
Frequent Flyer Program
Medical Information
Private Health Insurance (Optional)
Does the player have private health cover? YesNo
Health Fund Provider
Medical Details
Pre-existing Medical Conditions AsthmaFits of any typeHeart conditionDizzy spellsBlackoutsMigraineSleep walkingNightmaresDiabetes
Details (optional)
Does the player have any other medical condition? (Optional) YesNo
What precautions are to be taken in regard to the medical condition?
Medication Information
Does the player receive any regular prescribed medication? YesNo
Details
When is it to be given?
How is it to be administered?
Allergy & Dietary Information
Allergy Details
Does the player suffer from any allergies? YesNo
Dietary Details
Is any special diet/care required? YesNo
Emergency Contact Information
Healthcare Practitioner Details
Doctor Name *
Practice Name *
Phone Number *
Emergency Contact Details
Contact Name *
Contact Relationship
Contact Phone Number *
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Subject Academy ProgramSchool Holidays ProgramOther
Participant Info
Date of Birth*
School Year Level Year 7Year 8Year 9Year 10Year 11Year 12
Academy / Teams
Academy Applying For 15 and Under High Performance Academy17 and Under High Performance Academy
Role
Current Teams
Participant Skills
Bowling Speed FastSpin
Parent / Guardian Info
Parent/Guardian Name
Parent/Guardian Email
Touring
Are you considering joining the Tour for your nominated age group? yesno
Why do you think you'll benefit from joining a High Performance Academy?
