SUNSHINE COAST CRICKET

JUNIOR

REGISTRATION FORM 2015/16

Address Correspondence to selected club –

This form to be retained by the Club and all details entered onto My Cricket

Caboolture Sports Cricket Club

Player’s surname / Given names
Address / Postcode
Email Address
Home Phone No / Parent(s)/Guardian(s)
Names :
Date of Birth / / / / Parent(s)/Guardian(s)
Occupations/ Ph : / Ph: / Ph:
Played Last Year / YES NO / School attending:
How were you made aware of cricket sign
on this year: / 
 / School / School Coaching Clinic
Friend / 
 / TV / Newspaper
Other______
Has Your child attended a Have A Go Program in the Past 5 yrs: YES / NO

PARENT / GUARDIAN PARTICIPATION

As it is impossible to run the club without help, parent(s) /guardian(s) will be asked to participate. Would you please indicate in the boxes below, the activities in which you are able to participate.

 / Coach /  / Assist at Training /  / Manager /  / in2cricket support
 / Scoring /  / Umpiring /  / Committee / Other:

PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING

JUNIOR Indemnity

I, ______am a parent or legal guardian of the child whose details appear above. I agree to my child applying to and being allowed to participate in the activities of the club and associations (Queensland Cricket, Sunshine Coast Cricket Association Inc. and affiliated Clubs). In consideration of the club and associations allowing my child to take part in cricket, 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 in a serious manner. I fully accept and agree to bear those risks in my own right and on behalf of my child.

(b)To the full extent permitted by law I agree both on behalf of my child and in my own respective rights to absolve, indemnify, release and discharge QC, SCCA Inc and Affiliated Clubs and its officers, employees, representatives and agents (the indemnities) from any and all liability for any injury, loss or damage to my child however caused arising out of my child’s participation in the activities including without limitation as a result of acts of negligence by the indemnities.

In addition, I hereby agree and consent to the provision of the personal information regarding my child as set out in this form to the Sunshine Coast Cricket Association , Queensland Cricket Association Limited and Affiliated Clubs for use by them as they see fit in the course of their administration of cricket in Queensland. Queensland Cricket’s {and therefore SCCA’s} Privacy Policy is available at I consent to photographs or images of my child being published in newsletters, web sites, newspapers, brochures or any other media as decided by the SCCA Inc.

I have read, understood, acknowledge and agree to all the matters referred to in this statement, including the warning, release and indemnity.

Signed: ______Date: ______

Fees do apply and are at the discretion of each individual club

MEDICAL PRACTITIONERS
Family Doctor:
Address:
Phone No: / After Hours No:
Dentist:
Address:
Phone No: / After Hours No:
MEDICAL DETAILS:
Blood Group (if known) / Do you object to transfusions:
Do you take any regular medications?Yes/No
Have you had …
EpilepsyYes/No
Hepatitis AYes/No
Hepatitis BYes/No
DiabetesYes/No
Heart ProblemsYes/No
HerniaYes/No / Vision:
Do you wear?
GlassesYes/No
Contact lensesYes/No
Vaccinations …
Hepatitis AYes/No
Hepatitis BYes/No
Tetanus, if yes whenYes/No
Other:Yes/No / If other, please specify.
HIV Status (optional):
IN A CASE OF EMERGENCY, PLEASE CONTACT:
Name: / Relationship:
Address: / Daytime Contact No:
PARENTS’/GUARDIANS’ DETAILS:
Mother’s Name: / Daytime Contact No:
Father’s Name: / Daytime Contact No:
HEALTH CARE DETAILS:
Private Health Fund Details: / Medicare Details:
Name of Fund:
Membership No:
Level of Cover: / Medicare Number:
No. on Medicare Card:
Surname: / Given Names
Address:
Date of Birth: / Place of Birth:
Home Phone: / Mobile / Work:
Facsimile: / Email:

MEDICAL INFORMATION