CPA Swimming Meet & Gala Day

Registration Form

Date: Sunday, 12th April 2015

Time: 10am – 4pm

Venue: Sydney Academy of Sport, Wakehurst Parkway, Narrabeen

Registrations close: Friday, 27th March.

Personal Details:

Swimmer name:______

Address:______

Sex: F / M Age:______

Phone:______
Parents: Would you be willing to assist on the day (Time keeping, marshalling etc?): Yes / No

Email:______

Entry Fees: $10 for the first race; $5 per race after that; Family medley- free of charge

Distance / Stroke / Boys / Girls
25m / Freestyle / /
Backstroke
Breaststroke
50m / Freestyle
Backstroke
Breaststroke
Family medley
Names of those participating (4 participants):

Please send your entries to:

Lauren Hansen

Post: PO Box 6427, Frenchs Forest NSW 2086

Email:

An invoice will be sent to you once your registration has been received.

Cerebral Palsy Alliance Swimming Meet & Gala Day

Permission to Use Photographs/Video Footage

I, the undersigned give Cerebral Palsy Alliance my permission to use photographs/video footage of myself.

The photographs/video may be used for the following:

  • Cerebral Palsy Alliance Sport Presentations
  • General Community Promotions
  • For the education and training of athletes and coaches
  • for external publications or promotional activities outside Cerebral Palsy Alliance, including print, broadcast, electronic (e.g. website) or other medium

I understand that I am free to withdraw permission prior to the material being published by contacting Cerebral Palsy Alliance. I also understand that I will receive no payment, for the use of the photograph/video footage.

Name of Athlete

Address

Phone no.

Signature

Dated / / 2015

This signature must be witnessed by the Athlete’s parent or guardian, if the athlete is under the age of 18 years of age

Name

(for those signing on behalf of the above named)

Relationship to above: parent guardian

Cerebral Palsy Alliance Swimming Meet & Gala Day

Athlete Indemnity

I, the undersigned hereby agree Cerebral Palsy Alliance or anybody or association in any way with the conduct or participation in the Swimming Meet and Gala Day, Sunday, 12 April 2015 (of which persons, bodies or associations are severally and jointly included in the term ("identified”) shall not be deemed responsible or liable in any way for injury, to me sustained in, arising from, or function of nature held during the period of camp, or prior to or subsequent thereto if anyway connected with directly or indirectly with the said camp and hereby identify the indemnified against any actions, suits, cause of actions, demands, and claims by me and hereby agree (so) that the indemnified may act as our agents in incurring such expenses as and/or doing whatsoever is reasonably necessary for the benefit of me in conjunction with or arising out of any such illness or mishap.

Name

Signed Date

This signature must be witnessed by the Athlete’s parent or guardian, if the athlete is under the age of 18 years of age.

Name (parent/guardian)

Signed

Date