Sports fee subsidy Application

Club Name

Nominated team

Name of applicant player *

First

Last

Does the applicant have a government issued health care card? *

Yes
No

If not please provide a brief description to your knowledge of the financial hardship the family is experiencing

Has the club determined that the applicant could not play without support with fees.

Yes
No
Other

Age group of nominated team

Date of birth

Name of Club contact

Club address

Postal address if different to above

Email *

Phone Number

Is the applicant a new player for the club?

Yes
No

Payments will be made by Electronic Funds Transfer (EFT) if approved to the sports club. Please provide the following bank details for payment

Account Name

Bank account number

BSB

Play it On would like to publish the stories of the participants it helps fund and track their sporting participation. Will will use first names only in publications, do you agree to this?

Yes
No

Applicant and Parent/Guardian acknowledgement. All the information stated in the application is the best to my knowledge true and correct. Parent/Guardian details below to confirm if deemed necessary *

First

Last

Contact details of parent/guardian Phone or Email

As club contact I acknowledge to the best of knowledge the information provided here is true and correct. I certify that the player would not be able to play without this subsidy. I realise that should the applicant be successful but the player is unable or unwilling to join the club is obliged to return the full grant subsidy to Play it On. I understand and abide by the guidelines. Club contact signature and name below. *