GOLD COAST & DISTRICT CRICKET ASSOCIATION INC by HC120918125621

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									                           GOLD COAST & DISTRICT CRICKET ASSOCIATION                                          .
                            PLAYERS REGISTRATION FORM FOR 2011/2012                                       .
                                                Hat/Cap/Shirt Size.......   Amount Paid $………..    /   /   Receipt No……….

SURNAME          …………………………… GIVEN NAMES                                    …………………….………………..…
MAILING ADDRESS             ……………………………………………...................……………...………....
SUBURB           ………………………………………………................…                                 POSTCODE ……………….
DATE OF BIRTH           ……….…………… OCCUPATION………………………………….……
e-mail address          ………………………………………………....                                       (Fax)....………………….…...
PHONE       (Home) …………………… (Work) ……………………                                          (Mobile)……………..……….

I WISH TO REGISTER WITH                 BROADBEACH-ROBINA C.C. …………………………..…….
PREVIOUS CLUB/S (last 5 years)          ……………………………………                               SEASON/S         ……….……….
HAVE YOU OBTAINED A WRITTEN CLEARANCE                                   YES/NO       (ATTACH COPY)
DO YOU IDENTIFY AS BEING AN ABORIGINAL OR TORRES STRAIT ISLANDER?                                             YES/NO
ARE YOU AVAILABLE TO PLAY REPRESENTATIVE CRICKET? ie
1) QCA Dolphins         YES/NO          2) Q.C.C.A.          YES/NO          3) OTHER ............................ YES/NO
I undertake to observe the Rules and Regulations of the Gold Coast & District Cricket Association Inc. Any player
signing more than one Registration Form will be fined by the Association and shall be liable for his Membership
Fee to the Club from which they desire clearance.

PLAYERS SIGNATURE            …………………………………………...DATE…………………….…..
CONSENT TO DISCLOSURE
PRIVACY ACT
I acknowledge and agree that the personal details relating to me set out in this form, including without limitation
my name and address, may be provided to the Queensland Cricket Association Limited for use by that organisation
as it sees fit in the course of its administration of cricket in Queensland.

PLAYERS SIGNATURE            …………………………………………...DATE…………………….…..
INDEMNITY AND RELEASE
In consideration of being allowed to participate in cricket matches, training and associated events (Activities)
organised and/or supervised by Gold Coast & District Cricket Association (“Association”) I hereby acknowledge,
agree and confirm the following:

(a)     There are inherent risks associated with the Activities which may result in personal injury (even of a
        serious nature) to participants. I fully accept and agree to bear these risks.
(b)     To the full extent permitted by law I absolve, release, discharge and indemnify the Association, its
        officers, employees, representatives and agents (“Indemnitees”) from any and all liability for any injury,
        loss, cost, charge, expense or damage suffered by me however caused, arising from or incurred directly or
        indirectly as a result of my participation in the Activities, including without limitation, where caused by
        any act, omission, default or negligence of the Indemnitees.

PLAYERS SIGNATURE            …………………………………………...DATE…………………….…..

								
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