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ST JOSEPH’S NETBALL CLUB INC 17 Oldfield Place, Brookfield Qld 4069 Email - email@example.com Website: www.stjosephsnetball.com 2012 REGISTRATION FORM Day Season – Western Districts Netball Association Parent/Guardian Details (if under 18 years of age) Name Address for Correspondence Email Home Telephone: Mobile: Emergency Contact Details Name Home Telephone: Mobile: Player Details Surname First Name Date of Birth (dd/mm/yyyy) Address for Correspondence Home Telephone: Mobile: Email address: Medical Conditions (conditions, symptoms and treatment required) Netball Playing Experience Club/Year Last Played: Preferred Playing Positions: Fees 10 years and under (Born 2002 or later ) Cost : $245.00 (additional siblings $235.00) 11 years and over Cost: $280.00 (additional siblings $270.00) Bank Account Details (preferred payment method by EFT) Account Name – St Joseph’s Netball Club Bank – Bank of Queensland BSB – 124028 Account No – 20590212 Ref – Your Surname Please tick if paid and date of payment _____/____/2012 Can you help? We are always looking for people to join our Committee, Coach, Umpire, Manage a Team, or assist with other events throughout the year. If you can help in any of the areas listed below please complete and we will be in contact with you before the commencement of the season. Coach a Junior Team Coach a Senior Team Assistant Coach (must be 13yrs or older) Team Manager Learn to Umpire Umpiring (willing to assist with inexperienced umpires – training will be included) Attend Western Districts Delegates Meetings on behalf of the Club Assist with other Club events and raffles Other Membership Application and Declaration I ________________________________________________ (Name) of ______________________________________________________________________________________________ (Address) hereby apply for membership of St Joseph’s Netball Club. In so applying and in consideration of my application for membership being accepted I acknowledge and agree that: 1. If accepted I will be a member of the Western Districts Netball Assoc (WDNA) affiliated club St Joseph’s Netball Club (St Joseph’s). 2. I will be bound by the St Joseph’s Constitution and any By-laws made under it. 3. Insurance is in place that provides limited cover to me whilst I am performing or participating in any authorised or recognised WDNA activity (For insurance details contact WDNA). I can, in my own interests, seek and obtain personal insurances over and above the cover provided by WDNA. 4. Warning: Netball can be inherently dangerous. Serious accidents can and often do happen which may result in me being injured or even killed. I have voluntarily read and understood this warning and accept and assume the inherent risks in netball. 5. Exclusion of Liability: Except where provided or required by law and such cannot be excluded, I agree that it is a condition of my membership (if accepted) that St Joseph’s is absolved from all liability however arising from injury or damage however caused (whether fatal or otherwise) arising out of my membership and / or participation in any St Joseph’s Activity. 6. Release and Indemnity: In consideration of St Joseph’s accepting my application for membership I: a) release and forever discharge St Joseph’s from all claims that I may have or may have had but for this release arising from or in connection with my membership and / or participation in any St Joseph’s Activity; and b) indemnify and hold harmless St Joseph’s to the extent permitted by law in respect of any Claim by any person including but not only another member of St Joseph’s arising as a result of or in connection with my membership and / or participation in any St Joseph’s Activity. In this Clause 6 “claims” means and includes any action, suit, proceeding, claim, demand, damage, penalty, cost or expense however arising but does not include a claim in respect of any action, suit, etc. made by any person entitled to make a claim under a relevant WDNA insurance policy or under the St Joseph’s Constitution or any Bylaws. 7. Fitness to Participate: I declare that I am and must continue to be medically and physically fit and able to participate in any St Joseph’s Activity. I am not and must not be a danger to myself or to the health and safety of others. I will immediately notify St Joseph’s in writing of any change to my fitness and ability to participate. I understand and accept that St Joseph’s will continue to rely upon this declaration as evidence of my fitness and ability to participate. 8. Medical details: If you suffer or have suffered from any disease or physical or mental disability (e.g. epilepsy, diabetes, or any permanent disability to a limb, eye or ear) likely to affect your efficiency, it may affect your safety and the safety of the public. You should consult your medical practitioner and St Joseph’s prior to commencing any netball activity. 9. I have provided the information required on the registration form and I warrant that all information provided is true and correct. 10. This document cannot be amended. If I do amend it my application will be null and void. 11. Privacy: I understand that the information I have provided on the registration form is necessary for St Joseph’s. I acknowledge and agree that the information will be disclosed by St Joseph’s to WDNA and the State Association and will only be used for the Objects of St Joseph’s and to provide me with membership services. 12. I understand that I will be able to access my information through St Joseph’s and / or State Association. If the information is not provided my membership application may be rejected. I acknowledge that St Joseph’s may also use my personal information in accordance with the St Joseph’s Privacy By-law. 13. I may advise St Joseph’s if I do not wish to receive any St Joseph’s promotional material. 14. Copyright in photographs and right to use: I acknowledge and consent to photographs being taken of me during my participation in St Joseph’s Activities. I acknowledge that St Joseph’s owns the photographs and that St Joseph’s may use the photographs for promotional or other purposes without my further consent being obtained. 15. Uniform: I will keep my uniform in good condition and acknowledge that St Joseph’s reserves to the right to ask me to purchase a new uniform if my uniform is not in such condition. 16. Assistance required: I agree to provide support if required to either St Joseph’s or WDNA throughout the season and assist with activities such as, but not limited to, selling raffle tickets, BBQ / canteen duty, clean up, etc. 17. I have read, understood, acknowledge and agree to the above declaration including the warning, exclusion of liability, release and indemnity. I acknowledge that if my application for membership is successful I will be entitled to all benefits, advantages, privileges and services of St Joseph’s membership. Player’s Signature ___________________________________________ Date _____/______/ 2012 Name Printed: ___________________________________________ Parent’s Signature ___________________________________________ Date _____/______/ 2012 Where the applicant is under 18 years of age this form must also be signed by the applicant’s parent or legal guardian) Name Printed: ___________________________________________ I am the parent or guardian of the applicant. I expressly agree to be responsible for the applicant’s behaviour and agree to personally accept the conditions set out in this membership application and declaration including the provision by me of a release and indemnity in the terms set out above.
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