CROCS HOCKEY CLUB INC Registration Form PLAYER DETAILS

CROCS HOCKEY CLUB INC
Registration Form
Date:
/
/
PLAYER DETAILS
FIRST NAME
SURNAME
M/F
D.O.B
DIVISION
F/R LEVY
FEES
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
TOTAL AMONT DUE
1. I/we hereby give consent to/give consent on behalf of my child to play solely under the jurisdiction of the Gladstone Hockey Association Inc (GHA) and any of its
affiliated clubs. I/we pledge to abide by the rules and regulations of such organisations, including changes that may be made from time to time. I/we/my children have
not registered with any other GHA affiliated club for the current season, unless approval has been obtained for Dual Registration.
2. I/We acknowledge and agree that the personal details relating to me/my child as set out on this form, including without limitation, my/my child/ my children’s name and
address may be provided to Hockey Queensland Inc (HQ) or any of its affiliated members, for use by that organisation in the course of its administration of hockey in
Queensland.
3. There are inherent risks associated with any sporting activity or any sports related events (e.g. fundraising) that may result in personal injury (even of a serious nature)
to participants, volunteers and onlookers. I/We fully accept to bear the risks.
4. To the full extent permitted by law I/we agree to absolve, indemnify, release and discharge the Association, its officers, employees, representatives and agents
(Indemnities) from any and all liability for any injury, loss or damage to me/us/my children however caused including consequential financial or economic loss or
damage, arising out of my/my children’s participation in these activities including without limitation as a result of acts or negligence by the Indemnities.
5. HQ has arranged sports injury insurance cover for its registered players. Full details of the cover can be obtained from GHA. I/W e accept that it is my/our responsibility
to satisfy myself/ourselves as to the adequacy of the sports injury insurance arrangement; otherwise, it is our responsibility to arrange additional insurance cover to
meet our requirements.
6. I/We acknowledge that video recording and photographing may be used at times for promotional activities, training purposes or security evidence. I hereby permit GHA
or CROCS HOCKEY CLUB INC to make/use photos or videos of me/my children as it deems appropriate.
7. I/We have read and understood the GLADSTONE HOCKEY ASSOCIATION’S Code of Conduct and the CROCS HOCKEY CLUB’S Code of Conduct pertaining to
players, spectators, coaches and officials and I/we agree to abide by their intent.
NAME:
SIGNATURE:
NAME:
SIGNATURE:
INVOICE TO
SURNAME
FIRST NAME
POSTAL ADDRESS
RESIDENTIAL ADDRESS
PHONE (H)
EMAIL
(M)
(W)
PREVIOUS CLUB:
CROCS HOCKEY CLUB INC
Medical Form
Date:
/
/
EMERGENCY CONTACT DETAILS
1.
NAME
ADDRESS
PHONE: (H)
2.
(M)
NAME
ADDRESS
PHONE: (H)
(M)
DOCTOR:
PLAYERS’ GIVEN NAMES:
(W)
PLAYER 1
(W)
PHONE:
PLAYER 2
PLAYER 3
PLAYER 4
MEDICARE NO.
PLAYER 5
Please tick columns below for existing medical condition
EPILEPSY
FAINTING/DIZZY SPELLS
HEART CONDITION
DIABETES
EAR DISORDER
RESPIRATORY DISORDER
ALLERGIES
DENTAL PLATES/BRACES
Other relevant medical information:
I give permission for the coach to obtain medical assistance or apply basic first aid if deemed necessary:
NAME (PARENT/GUARDIAN/SENIOR PLAYER )
SIGNATURE
NAME (PARENT/GUARDIAN/SENIOR PLAYER )
SIGNATURE
PLAYER 6