Super Sports Sign-On Day REGISTRATION FORM Bundaberg PCYC

Super Sports Sign-On DayREGISTRATION FORMDate Sunday 12 February 2012TimeVenue10am - 1pmBundaberg PCYC (corner Walker & Maryborough Street)Getting involved in the Super Sports Day will give you the opportunity to promoteyour organisation/club and be a part of another great event brought to you by the QueenslandGovernment at PCYC BUNDABERG (corner Walker & Maryborough Street).The aim of the day is to encourage members of the community to sign up to sport and recreationactivities. It is a great opportunity to:• Promote sporting and recreation activities and including interactive displays;• Recruit participants and volunteers for local organisations;• Promote the benefits of being involved in sport and healthy lifestyles messages; and• Provide community information about the opportunities in their local area.Important information:o Registrations close Monday 6th February 2012;o The format of the day will include static displays and a series of practical demonstrations fororganisations to promote their activities/ sport;o Organisations will be allocated a site and display area. Details of this will be provided prior tothe event and no site fees are required;o Organisations must be available on the event day for pre set up at 8am, to staff your display forthe duration of the event 10am – 1pm and post event to dismantle your display;o Vehicles are to be removed to a parking area by 9am;o All sites must be presented in a neat and tidy manner and are only to provide information onyour club or sport;o All rubbish must be removed from each site at the conclusion of the day;o Should your organisation/club wish to undertake activities (come and try etc), these need to beconducted in a safe and controlled manner. You must discuss any activities with the departmentcontact as listed on the form;o To participate in the day, your organisation must have Public Liability Insurance. You will needto provide the department with a copy of the Certificate of Currency prior to your registrationform being considered by the department; ando Registrations are limited. Registration forms will be considered on a first-in, first served basis.o By submitting a registration form Organisation’s are not guaranteed a display at the event. Thedepartment will consider each form submitted and may in its absolute discretion and withoutexplanation accept or decline registrations to participate in the event. The department willinform accepted organisations/clubs by either phone or email prior to Tuesday 7th February2012 or asap after registration.Interested in being a part of the Super Sports Sign-On Day? Then please complete theRegistration form and send with a copy of your current Public Liability Insurance certificate to thefollowing address by asap or by Monday 6th February February 2012:Email: linda.kleinschmidt@communities.qld.gov.auMail: Attention Linda - Sport & Recreation Services PO Box 618 BUNDABERG 4670Should you have any queries, please telephone: 0419 679 494

Super Sports Sign-On Day - REGISTRATION FORMOrganisation NameSport/ ActivityPostal AddressContact personPhoneEmailNamePositionHomeMobileWorkFaxPlease indicate if your organisation is interested in the following:Practical demonstration Yes NoIf yes, please provide as brief description and the expected duration:_______________________________________________________________________Providing your own marquee/displays Yes NoIf yes, please provide the dimensions:_______________________________________________________________________Main Contact person on the day of event:NameMobileThe Organisation, by its authorised representative, offers to participate in the event on the terms outlined in thisform. The person signing agrees that they have the appropriate authority to sign on behalf of the Organisation.NamePositionSignatureDatePrivacy statement - The information collected on this form is collected under the Information Privacy Act 2009, and will be used by theDepartment of Communities for purposes associated with the registration process and/or your attendance at the Super Sports Day. Thisinformation may be stored in a Department of Communities database and may be disclosed to units within the department for purposesassociated with promoting physical activity including workshops and resources. Your personal information will not be provided to any otherperson external to the Department without your consent, unless required by law. The information collected will be retained as required bythe Public Records Act 2002 and is subject to the Right to Information Act 2009. For further information on your privacy, contact the PrivacyContact Officer for the Department of Communities at privacy@communities.qld.gov.au.Acknowledgement - The Organisation acknowledges that the department is not responsible for any risk or injury that occurs to any personas a result of activities carried out at the Organisation’s display. The Organisation accepts sole responsibility for the activities conducted aspart of its display and participation at the event, and any claims that should arise as a result. Acceptance of the registration does not implyyour organisations activities eligibility for other Sport and Recreation initiatives (eg funding programs).By participating in the event, your Organisation may be entered in the draw to win a prize. Not all events will have a prize draw forparticipating organisations and the nature of the prize may not be known until the day of the Event. The terms and conditions for thegiveaway may not be available until closer to the Event. You acknowledge that it is your responsibility to ensure that you have read anyterms and conditions that relate to the giveaway and advise the Departmental contact officer if your Organisation does not wish toparticipate.