White Hills Junior Cricket Club - Player Registration

Season 2016/17

The information listed will be used for the registration of the player along with contact details for the club. Please ensure that the form is filled out clearly and completely. Thank you.

SURNAME:______GIVEN NAME:______

AGE GROUP: Milo (Beginners – Under 8) U10 (T20 Blast) U12 U14 U16 (Please circle)

Age is as at the 1st of October

Home Address: ______

Postal Address: ______

Home Phone: ______Mobile: ______Sex:M / F (Please circle)

Email: ______Date of Birth: ____/____/______

Are you Aboriginal or Torres Strait Islander origin? Yes No (Please tick)

Did you play with WHJCC last season? (Please tick) Yes No

Or are you a new player to the club? (Please tick) Yes No

Orare you transferring fromanother club? Name of club ______

Parent/Guardian information for Emergency Contact

Name: / Relationship
to Player / Contact Phone No.
Primary Contact
Secondary Contact

Players Medical Details

Doctors Name: / Phone Number: / Address:
Private Health Insurance: (Please tick) /
Yes No / Membership Number:
Allergies:(Please give details)
Other medical issues:

Player Access Restrictions


Is the player at risk? Yes No

Is there an Access Alert for the player? Yes No

Access type:(Please tick) Court Order Family Law Order Restraining Order Other
Describe any Access Restrictions:

Parental Consent:

(Please tick)

As a parent/guardian of the above-mentioned player, I hereby give my consent for him/her to participate as a member of the White Hills Junior Cricket Club Inc. team/s and agree that the Club will not be held responsible for any injury or loss of property during games, training and activities held by the Club.

I hereby give my permission for any and all MEDICAL attention found necessary, to be administered or sought for my child in the event of an accident, injury or sickness whilst under the direction of the Team Coach and Manager until such time as I the Parent/Guardian can be contacted. I agree to meet any medical expenses incurred therein. Please note that in an emergency, an ambulance MAY be called. If I don’t have ambulance cover I understand the implications and personal financial liability.

I grant permission for the WHJCC to use photographs of my child for the purposes of club promotions, website, advertising and newsletters.

I agree that both the abovementioned player and I will abide by the BDCA Code of Conduct. I support the club in its undertakings and encourage the club to take any disciplinary action including the suspension and banning where warranted of any players, parents or spectators for repeated or serious breaches of this code and will accept their decision.

Are you able to help out with your child’s team with any of the following roles?(Please tick)

Team Manager Coach Assistant Coach

Assist coach with training Scorer Fund raising

Working with Children Check Yes No Card No. ______

/Do you have a current First Aid Certificate? Yes No

Privacy:

The White Hills Cricket Club will collect, store and use this personal information and, at all times, observe the confidential nature of the in formation. In an emergency where, after our best endeavours to obtain your consent or the consent of the emergency contact person ( as stated in this document) or where it is not possible or reasonably practical that such consent be obtained we may disclose this information without consent so we may provide medical assistance to the player should an injury be sustained and medical assistance is required.

Declaration:

I give my consent to the above named person to play cricket. I accept full responsibility for loss or injury incurred while playing, training or traveling to and from locations associated with the Bendigo District Cricket Association Inc. I accept the conditions prescribed by this association.

Print Name: ______Signature: ______Date: ______

Parent/Guardian

If you have any queries regarding registration please contact Junior Co-ordinator Andrew Stewart M. 0403 942 551 E.

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