Leichhardt Saints Football Club (page 1 of 2)

PO Box 821, LEICHHARDT, 2040

Registration Application for Club Officials, Ground Officials, Coaches and Managers 2017

FFA Registration Number: ……………… Current Coaching Qualifications:……………….

Your Details:

Given Name(s): ...... …..Surname:......

Address: ......

Suburb: ...... State:………. Post Code: ......

Age turning during 2017: …………. Gender:……… Date of birth:......

Country of Birth:………………………………………… Nationality:......

Working with Children check number ……………. Application Number …………………….

Application for:

Coach Manager Ground Official 
Club Official (state role) ......

Team (for coaches, managers and ground officials)

Team - age/division …………………...... (or team coached/managed last year) ……………………

Contact details (*mandatory field for at least one of email or mobile)

Home phone:...... Email*......

Work phone...... Mobile*......

These details are required by the Club should it be necessary to contact you, and are also a requirement of registration with Football Federation Australia.

Special offers for CDFSA, FFA and their partners
Official use only
Officials ID Original sighted
Copy obtained
N/A (returning player) / Type of ID Birth Certificate
Passport
Drivers Licence/RTA ID / Officials HandbookIssued: YES
Note: Must be Issue to ALL officials / Photo ID
Current File Photo OK
New Photo Taken
Form received and
checked by(initials): ……………….… / Date received (if not reg day):
……………………………… / Processed
(Registrar)………………………………
Taken By: ……………………Date Taken: …………………….

I do NOT want to receive special offers from Football Administrators partners.

Please sign on page 2 over

Leichhardt Saints Football Club (page 2 of 2)

Registration Application for Club Officials, Ground Officials, Coaches and Managers 2017

APPLICANTS DECLARATION:

I, in volunteering to undertake official duties for and on behalf of LSFC, hereby declare,

  • I have received a copy of the current LSFC Officials Registration Handbook
  • I agree to abide by the CDSFA Code of Conduct for coaches/managers/officials (as applicable) a copy of which is contained within the LSFC handbook.
  • I will abide by the Rules of the Association, Zero Tolerance Policy and any decision(s) of Canterbury and District Soccer Football Association Inc. (CDSFA),
  • I acknowledge that the CDSFA may take disciplinary action against me, if I breach the code of conduct. (I understand that the CDSFA is required to implement a complaints handling procedure in accordance with the principles of natural justice, in the event of an allegation made against me).
  • I acknowledge that disciplinary action against me may include de-registration and/or suspension and or fine by the CDSFA.
  • I am willing to follow directives of the Club Executive or their nominated officials and to abide by the Club’s policies, codes, rulings or decisions made from time to time by the LSFC committee,
  • I understand that LSFC will undertake to exercise all reasonable care in the conduct of its activities, but declines to accept responsibility for accidents occurring as a consequence of my participation in such activities, and
  • I am not under suspension by any sporting organisation.
  • I understand that I will be included on the LSFC mailing list so I will have all the latest information.

Permission for use of photos:

  • I grant permission for photos of me that may be taken during games or events throughout the football season to be used in Club publications, including the Club web site, and by the Football Federation of Australia, Football NSW and the Canterbury District Football Association for the general marketing and promotion of football. No names of players under the age of 18 will be used in conjunction with photos when published on the LSFC web site without separate express permission.

[If you have reason not to make this declaration, or grant photo permission, please see a club official at time of making this application]

Prohibited Persons Declaration (Child Protection)

In volunteering for a role in an official capacity for LSFC associated with coaching, instruction, care or management of children, I declare that;

  • I am not a person prohibited by the Commission for Children and Young People Act 1998 from seeking, obtaining, undertaking or remaining in child related employment.

I have read and understood the information in relation to prohibited persons contained within the LSFC Officials Registration Handbook and am aware that it is an offence to make a false statement on this form.

I am aware that I am ineligible to apply for or otherwise attempt to obtain, undertake or remain in, child related employment if I have been convicted of a serious sex offence or child-related personal violence offence as defined in the Commission for Children and Young People Act 1998, or if I am a Registrable Person under the Child Protection (Offenders Registration) Act 2000

Should the Club be required by law, I consent to this information being submitted to the NSW Commission for Children and Young People and/or to NSW Police, to verify the statements I have made here, and/or for law enforcement purposes and for monitoring and auditing compliance with the procedures and standards for the Working With Children Check in accordance with Section 36 (1) (f) of the Commission for Children and Young People Act 1998.

I accept the above conditions and confirm my details and all declarations on this form are correct and true;

Applicants Signature ...... ……………………………… Date:......

Parent/guardian Co-signature if under 18:...... Date:......