WYNDHAM QUICK STIX LACROSSE

WYNDHAM
QUICK STI
CHALLENGE
CATCH & THROW, GIVE LACROSSE A GO!
2015 E
S
LACROSSTIX
QUICK NGE
CHALLE
R
E
T
S
I
G
E
R
NOW!
Register at lacrossevictoria.com.au/quick-stix/
to receive a promo pack which includes a
lacrosse stick, ball, tshirt & wristband!
WYNDHAM
QUICK STI
PARTICIPANT REGISTRATION FORM
PARTICIPANT DETAILS
CHALLENGE
MEDICAL INFORMATION
6. Medical
Surname:
Does your child have a disability or any special needs?
First Name:
Yes
No
Yes
No
If yes, please specify
Address:
Does your child have any allergies
or is he/she allergic to any medication?
Suburb:
In an emergency, do you authorise the Quick Stix Lacrosse Yes
No
centre coordinator to arrange any necessary medical treatment
for your child where prior notification has not been possible and agree to
cover any associated costs of treatment and/or transportation?
If yes, please specify
School:
INDEMNITY: Except where provided or required by law and such cannot be
excluded, I agree that the Quick Stix Lacrosse Centre and its respective directors,
officers, members servants or agents are absolved from all liability arising from
injury or damage to my child, however caused, whilst participating in the
Quick Stix Lacrosse program.
How did you hear about us?:
State:
Post Code:
D D
DOB:
Gender:
T-Shirt Size:
M M
/
/
Male
Y Y Y Y
6
No
Age:
Female
8
10
12
DECLARATION
Language/s other than English
spoken at home?
Do you identify as an
Aboriginal/Torres Strait Islander?
Yes
IMAGE CONSENT: I provide consent for the Quick Stix Lacrosse Centre
to record my child’s image (photograph or video footage) for promotional
purposes. I understand my child’s image may be used in mediums including:
publications and promotional material, and broadcast, print and electronic
media. I acknowledge that my child’s image will be used without any personal
compensation or remuneration. I agree to forgo any rights to my child’s image
including moral rights and copyright.
Undisclosed
Yes
• I agree to pay all fees by the date(s) specified
• I agree (member and parents) to comply with Lacrosse Victoria's
Constitution, By-Laws, and Policies, including but not limited to the
Lacrosse Victoria Member Protection Policy.
No
If yes, please specify the language/s:
• I understand that the personal information provided on this form will be
used to administer Quick Stix and for related purposes including providing
you with information in relation to Quick Stix, the sport of Lacrosse and
promotional offers.
This information is vital to help Lacrosse Victoria provide fair, safe and inclusive
environments for all. Data will also help your Quick Stix Lacrosse Centre and
Lacrosse Victoria seek applicable funding to provide greater opportunities.
• I understand that if I do not provide the information requested on this form,
the Quick Stix Lacrosse Centre might not be able to process my registration
and I will not be eligible to become a member or compete in the
competitions/programs.
PARENT / GUARDIAN DETAILS
(Emergency Contact)
Surname:
I have read, understood and agree to the above terms and I personally
consent to the application of my child. I warrant that all information provided
is true and correct.
Name:
First Name:
Date:
Phone No.:
D D
/
M M
/
Y Y Y Y
Signed: (Parent or legal guardian of participant)
Mobile No.:
Email Address:
EVENT INFORMATION
Centre:
Dates:
Wyndham Centre
Monday, 2 March
Monday, 23 March
Monday, 13 April
Monday, 27 April
Wootten Road Reserve
Wootten Road, Tarneit
Time:
Monday, 16 March
Monday, 30 March
Monday, 20 April
Monday, 4 May
5:00pm - 6:00pm
For further event information and details please contact Lacrosse Victoria
on 9926 1390 or email at [email protected]
QUICK STI