toombul district cricket club inc – junior division - Queensland Cricket

PLAYER DETAILS
Tick if returning player
TOOMBUL DISTRICT CRICKET CLUB INC – JUNIOR DIVISION
PO BOX 450, NUNDAH QLD 4012
www.qldcricket.com.au/clubs/toombuljuniors
ABN 58 681 141 641
REGISTRATION FORM 2011-2012
If applicable, please nominate the Toombul team
you played with last year eg 10 Red or any
players you would like to play with this season.
SCHOOL (Before Christmas) (After Christmas)
NAME
ADDRESS
BIRTH DATE
SHIRT SIZE
MEDICAL
INFORMATION
GIVEN NAMES
SURNAME
STREET SUBURB POSTCODE
Full Season
Half Season
Please Circle One
8 10 12 14 16 Medium Mens
PLEASE CIRCLE ONE
Does the player have any medical condition which the team manager should be aware of? Please
circle NO or if YES specify:
PARENT / GUARDIAN DETAILS
Mother / Guardian
Father / Guardian
Name
Occupation
Mobile
Email Address
As parents / guardians, you will be required to assist from time to time as scorer and umpire. Your involvement
is also encouraged in one of the following capacities. Please indicate your preference:
Coach Manager Assistant Coach Assistant Manager
Committee Member Photo Day / Trophy Day Fundraising Sponsorship
PLEASE CIRCLE ONE
FEES PAYABLE for 2011/2012 SEASON
Fees including match fees (balls and ground hire) and GST are:
FULL SEASON HALF SEASON
First child per family $160 $140
Second and subsequent child $120 $100
PLEASE CIRCLE AMOUNT
PAYMENT OPTIONS (Please tick method of payment)
If 2 nd child, please note other
child(ren) and ages:
CASH CHEQUE DIRECT DEPOSIT
Payable to:
“TDCC – Juniors”
Mail Form & cheque To:
PO Box 450
Nundah 4012
Amount to be Paid $
Please scan registration form to:
Toombul@clubs.qldcricket.com.au
A/C Name: Toombul District Cricket Club Inc
Bank: Commonwealth Bank, Cannon Hill
BSB: 064 142
Account No: 0090 3270
(Please detail player(s) name in deposit)
Office Use Only
Paid $___________
Date: / /
Receipt No. _________
Received By: _________
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TOOMBUL DISTRICT CRICKET CLUB INC – JUNIOR DIVISION
PO BOX 450, NUNDAH QLD 4012
www.qldcricket.com.au/clubs/toombuljuniors
ABN 58 681 141 641
REGISTRATION FORM 2011-2012
INDEMNITY and CONSENT TO DISCLOSURE PRIVATE ACT
I ____________________________________ am a parent or legal guardian of_________________________________ (my child).
I agree to my child applying to and being allowed to participate in the cricket matches, training and associated events, ("Activities")
organised and/or supervised by Toombul District Cricket Club Inc and Brisbane North Junior Cricket Association Inc during the
2011/2012 Season. In consideration of the Club and the Association allowing my child to take part in the Activities, I acknowledge,
agree and confirm the following:
a) That there are inherent risks associated with the Activities which may result in my child being injured, including
b) That it will be my responsibility to ensure that my child wears protective clothing and sun protection cream as laid down by
the rules and conditions of play set down by the Association.
c) That the Club and the Association and their officers, employees, representatives and agents are authorised to obtain all
such medical assistance and treatment for my child as shall, to it or them, seem desirable and I undertake to pay all fees
and expenses so incurred and to indemnify the Club and the Association in respect of same.
d) To the full extent permitted by law I agree both on behalf of my child and in my own right to absolve, indemnify, release
and discharge the Club and the Association and their officers, employees, representatives and agents ("Indemnitees'')
from any and all liability for any injury, loss, cost, expense or damage suffered by me or my child however caused, arising
from or incurred directly or indirectly as a result of my child's participation in the Activities, including without limitation as a
result of any act, omission, default or negligence by the Indemnities.
e) I consent to Toombul District Cricket Club Inc promoting youth in cricket by publishing photographs of my child participating
in cricket for the club brochures, newsletters or on the web page of the club.
We would draw your attention to further details of our insurance scheme on www.bnjca.org.au
I also agree and consent to the provision of the personal information regarding my child and ourselves as set out in this form to:
f) The officials of the team in which my child is playing (including health information in this instance);
g) Brisbane North Junior Cricket Association Inc and Queensland Cricket Association Limited for use by them as they see fit
in the course of their administration of cricket;
h) Personal information of the parents or legal guardian (only) to the sponsors of the Club;
I have read, understood, acknowledge and agree to all the matters referred to in this statement, including the warning, release and
indemnity. I also agree to be bound by the rules and conditions of membership of the Club including:
i) No player will be registered unless they have paid their fees in full or made suitable arrangements with the Treasurer. All
registrations must go through the clubs registrars;
j) I understand the fees cover:
Membership of Toombul Cricket Club
Insurance with Queensland Cricket
Affiliation fees with Brisbane North Junior Cricket
Provision of equipment including match and training
balls
Trophies for all players at the end of season trophy day
Team photo
Playing shirt
Cap (new Players only)
k) I understand that all parents are expected throughout the season to assist in the running of the club. I am willing to assist
as nominated on the previous pages.
l) I shall conduct myself in a sporting manner at all times whilst representing the club.
m) As a parent I shall conduct myself at all times in line with the Qld Cricket Code of Conduct for spectators and parents,
realising that Junior Sport is for the players and the children participating.
Signed
Date
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