PERSONAL DETAILS – PLAYERS/NON-PLAYERS ONLY:

SURNAME / Given Names
Address / Postcode
Phone (H) / (WK) / (MOB)
Email / Would you like correspondence/ q Yes
newsletters sent to you via email q No
Occupation (Seniors Only) / Employer (Seniors Only)
Full time student – Playing Seniors only (if yes - ID is required) q Yes / Date of Birth:
Blue Card Expiry
Medical Particulars e.g. Allergies, Asthma, Diabetes, Epilepsy etc that you feel Commercial Hockey Club should be aware of
PARENT’S/GUARDIAN’S DETAILS (Only for players Under 18): (Same address, email & phone numbers as above please fill-in AS ABOVE)
SURNAME / Given Names
Address / Postcode
Phone (H) / (WK) / (MOB)
Email / Would you like correspondence/ q Yes
newsletters sent to you via email q No

MEMBERSHIP FEE DETAILS: (Please select which membership you require)

q ORDINARY MEMBERSHIP FEE $11.00 This entitles the member to full voting rights and includes all players over 18

q ASSOCIATE ASSOCIATE FEE $5.50 For non playing members who do not require voting rights

MEMBERSHIP TYPE: (Please tick appropriate membership)

q FULL TIME SENIOR ONLY - q Turf q Grass q Veterans/Masters / q SECONDARY (Commercial) DUAL REGISTERED PLAYER
q LIFE MEMBER / q FULL TIME JUNIOR (U17) PLAYING JUNIORS & SENIORS
q ASSOCIATE MEMBER / q FULL TIME JUNIOR (U17) PLAYING SENIORS ONLY
q NON-PLAYING CLUB MEMBER (eg. Coach, Manager, Admin, etc) / q FULL TIME JUNIOR PLAYING JUNIORS ONLY

PLAYING DETAILS: (A clearance from your previous club must accompany this form)

POSITION LAST PLAYED:……………………………………………….. PREFERRED POSITION:………….…………………………………...

DIVISION LAST PLAYED:……………………………………………….. PREVIOUS CLUB:……………………………..……………………..…..

PLEASE NOTE: (Under 18 Only) If you are a new member a copy of a Birth Certificate must accompany this form.

Which division would you like to be selected for? q U7 q U9 q U11 q U13 q J Turf q J Grass

Do you wish to be a reserve for seniors? q Yes q No

Do you intend playing GPS competition? (Girls only) q Yes q No

Are you interested in learning to umpire? q Yes q No

Are you prepared to assist other junior umpires? q Yes q No

I, the undersigned, hereby make an application as a member of Commercial Hockey Club Inc for the coming season.

I acknowledge that playing, training for, observing hockey or participating in any activity/event organised by the club, are activities that inherently involve risk and that by undertaking these activities I or my child do so at my own risk. As such, Commercial Hockey Club Inc requires the wearing of all protective equipment including but not limited to shin pads and mouthguards. Commercial Hockey Club Inc will not seek medical or other information to determine a player’s fitness to participate in the game of hockey. I declare that I or my child is in good physical health, sufficient to participate in training and playing hockey. Player insurance is provided by Hockey Queensland, however a player is not covered until such time as they satisfy the requirements of membership of Commercial Hockey Club Inc, which requires the completion and submission of this form with sign-on fees.

Commercial Hockey Club Inc is committed to adhering to the National Privacy Principles outlined in the Privacy Act and therefore declare any information contained in this application will be used exclusively in accordance with the operation of the club and it’s associated bodies. All information will be stored securely and not released without prior permission of the member. I further release Commercial Hockey Club Inc and any of it’s office bearers, agents or representatives from any and all liability for any loss, damage or injury arising from participation in activities incidental to the operation of the club.

I hereby declare, I have read and understood the nature and effect of this application and therefore agree to be bound by the rules and by-laws of Commercial Hockey Club Inc, which includes presenting for training and games as required.

______

Players/Non-Players/Parent’s/Guardian’s Signature Date

SIGN ON FEES: Seniors - $250.00; Juniors - To be advised This fee must accompany this form as part payment.


FOR CLUB USE ONLY

Paid $ Receipt No: Date: Initial: Membership No: