Super Sports Sign-On Day REGISTRATION FORM Bundaberg PCYC

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.