Team Nomination Form for Social Sports
Section 1: Social Sport Selection
Floorball Indoor Soccer Volleyball
League Selection:______
Section 2: Team Name and Contact
Team Name______
Primary Contact Name______
Contact Numbers______(HM)
______(MB)
Email______
Secondary Contact Name______
Contact Numbers______(HM)
______(MB)
Email______
Section 3: Previous History of Team Nominated
Have the majority of players participated in this sport before?
YES NO
PLEASE NOTE: Whilst we recognise the need of teams to introduce new players during the season, we reserve the right to not allow teams to increase their strength beyond the capacity of the grade. In such circumstances Northam Recreation Centre reserves the right to deem the game a forfeit.
Your players Details
Full NameEmailMobile Phone
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The Shire of Northam requests that each Team Sports team must provide/nominate an umpire for games.
Nominated Umpire:______
Section 4: Other details
Shirt Colour______
Shorts Colour______
Section 5: Cost
Each player per game pays$6
Forfeit Fee: $26 (court hire fee)
Floorball Stick Hire $2
Spectator Fee: $1
I, ______declare that, as team captain, I will be responsible to ensure that all players who represent this team name will, for the duration of the season, including any finals, honour all forfeit fees, surcharges and suspensions that may be imposed on the team by the competition officials of the Shire of Northam.We, as a member of this team, declare that on signing this form accept the competitions fee’s and charges are subject to change and may increase as per the annual review. We acknowledge and declare that the team participants will conduct their behaviour in accordance with Shire of Northamcode of conduct and accept any penalties incurred for violating these standards. We also declare that we understand that taking part in any competition may expose a team member to the possible risk of injury and that the Shire of Northam is not liable for any injury, damages or costs incurred by players as a result of an injury of any nature suffered during the course of play in the competition or in respect to that occurring on the Recreation Centre and its grounds, except to the extent of negligence by the Shire of Northam and indemnify the Shire and its employees in respect thereof. We understand that by playing with an existing injury or pregnancy we may put our bodies at further risk. All players play at their own risk.
Staff Use Only
Code of Conduct received YES/NO
Date:______