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Title :	Mr Mrs Miss Ms Dr Prof
First Name :	*
Middle Name :	Please enter a middle name if you have one
Last Name :	*
Preferred Name :
Date Of Birth :	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Year
Male / Female :	Male Female *
Insurance Status :	Select Status Student Non Student
Country of Birth :	Australia United Kingdom (UK) United States of America New Zealand ------------------------------------- Afghanistan Albania Algeria Andorra Angola Antigua & Barbuda Argentina Armenia Austria Azerbaijan Philippines Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia & Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo (Dem. Rep. of ) Congo (Rep.) Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea (North) Korea (South) Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Phillipines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts & Nevis Saint Lucia Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Serbia & Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka St. Vincent & the Grenadines Sudan Suriname Swaziland Sweden Switzerland Syria Tajikstan Tanzania Thailand Togo Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe
Nationality :	Australian New Zealander British American --------------------------------- Afghan Albanian Algerian Andorran Angolan Antiguans Argentine Armenian Austrian Azerbaijani Bahamian Bahraini Bangladeshi Barbadian Belarusian Belgian Belizean Beninese Bhutanese Bolivian Bosnian Herzegovinian Batswana Brazilian Bruneian Bulgarian Burkinabe Burundian Cambodian Cameroonian Canadian Cape Verdian Central African Chadian Chilean Chinese Colombian Comoran Congolese Congolese Costa Rican Ivorian Croat Cuban Cypriot Czech Dane Djibouti Dominican Dominican East Timorese Ecuadorean Egyptian Salvadoran Equatorial Guinean Eritrean Estonian Ethiopian Fijian Finn French Gabonese Gambian Georgian German Ghanaian Greek Grenadian Guatemalan Guinean Guinea-Bissauan Guyanese Haitian Honduran Hungarian Icelander Indian Indonesian Iranian Iraqi Irish Israeli Italian Jamaican Japanese Jordanian Kazakhstani Kenyan I-Kiribati North Korean South Korean Kuwaiti Kyrgyz or Kirghiz Lao or Laotian Latvian Lebanese Mosotho Liberian Libyan Liechtensteiner Lithuanian Luxembourger Macedonian Malagasy Malawian Malaysian Maldivan Malian Maltese Marshallese Mauritanian Mauritian Mexican Micronesian Moldovan Monegasque Mongolian Moroccan Mozambican Burmese Namibian Nauruan Nepalese Dutch Nicaraguan Nigerien Nigerian Norwegian Omani Pakistani Palauan Panamanian Papua New Guinean Paraguayan Peruvian Filipino Pole Portuguese Qatari Romanian Russian Rwandan Kittian and Nevisian Saint Lucian Samoan Sammarinese Sao Tomean Saudi Senegalese Serbian Montenegrin Seychellois Sierra Leonean Singaporean Slovak Slovene Solomon Islander Somali South African Spaniard Sri Lankan Sudanese Surinamer Swazi Swede Swiss Syrian Taiwanese Tajik Tadzhik Tanzanian Thai Togolese Tongan Trinidadian Tobagonian Tunisian Turk Tuvaluan Ugandan Ukrainian Emirian Uruguayan Uzbek Ni-Vanuatu Venezuelan Vietnamese Yemeni or Yemenite Zambian Zimbabwean
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Contact Information:

Home Phone Number :	*
Work Phone Number :
Mobile Number :	Receive Club SMSs?    Yes No
Main Email Address :
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2nd Email Address :
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Parents Details:

Parents Title :	Mr Mrs Miss Ms Dr Prof
Parents Name :
Male / Female :	Male Female
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Mobile Phone Number :	Receive Club SMSs?    Yes No
Main Email Address :
Receive Club Emails?	Yes No
2nd Email Address :
Receive Club Emails?	Yes No
Parents Title :	Mr Mrs Miss Ms Dr Prof
Parents Name :
Male / Female :	Male Female
Parents Occupation :
Home Phone Number :
Work Phone Number :
Mobile Number :	Receive Club SMSs?    Yes No
Main Email Address :
Receive Club Emails?	Yes No
2nd Email Address :
Receive Club Emails?	Yes No

School Details:

Additional Information:

Non Disclosure :	No Yes YES if the Player does NOT want details disclosed to others in the Club Click for Explanation
Receive QCSA Emails :	Yes No No if the Player does NOT want to receive emails from QCSA
Special Offers :	Yes No No if the Player does NOT want to receive Special Offers from Football Administrators partners
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