Personal Information

First Name*

Surname*

Address*

Date of Birth*

Contact Number*

Email Address*

Occupation*

Polo Shirt Size*
SMLXLXXLXXXL

St Marys Rugby League Club Membership Number*

Club History

Are you a past/present member of St Marys Rugby League Club?*
YesNo

Please state number of year’s service with St Marys Rugby League Club:
Coaching:*

Playing:*

Other:

Training Qualifications

Do you hold a current Trainers Accreditation?*
YesNo

League Safe (Yellow Shirt)*
YesNo

Penrith Registration Number:

Year:

Sports Trainer Level 1 (Blue Shirt)*
YesNo

Penrith Registration Number:

Expiry:

Sports Trainer Level 2 (Orange Shirt)*
YesNo

Penrith Registration Number:

Expiry:

Are you a New Trainer?*
YesNo

Would you like to attend a Trainers course:*
Yes, League SafeYes, Trainer Level 1Yes, Trainer Level 2No

Have you completed a current Working with Children Check?*
YesNo

Working with Children Check Number*

Expiry Date*

Team Nomination

Name the age team you would like to Manage:*
Age:

Division:

Do you have a child playing in this team?*
YesNo

By completing this form, I hereby acknowledge and I will abide by the St Marys Junior League Registration policy document which details the values of our club and what is expected.