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PARTICIPANT_PLAYER MEDICAL PROFILE

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PARTICIPANT_PLAYER MEDICAL PROFILE Powered By Docstoc
					       SENIOR REGISTRATION AND MEDICAL PROFILE RECORD
                         SEASON 2009

All information on this sheet is confidential. Access to this sheet is limited to committee members and coaches and
relevant medical staff. This information will be treated in accordance with the club’s privacy policy. See Privacy
Statement below.

Club Details – www.easternblades.org.au

                                                 Personal Details

Surname: ______________________                        First Names: ___________________________

Address: ___________________________________________________

               _________________________________                      Post Code: _________________

Home Phone: _____________________                     Mobile Phone: _________________________

Email Address: ________________________________ Partner’s Name: ___________________

Sex:      M                     F            Date of Birth: ____/____/____


2008 Competition Grade: _________________                      Club: ________________________________

ARE YOU A GOALKEEPER WITH YOUR OWN EQUIPMENT?                                              Yes/No

OCCUPATION: ________________________                           EMPLOYER: __________________________

ARE YOU SEEKING TO PAY THE CONCESSIONAL FEE RATE?                                                   Yes/No
Please tick relevant category


Student

Centre-link Concession

Other                                        Details: ___________________

                                         Emergency Contact Details

Surname: __________________________ First Names: _____________________________

Home Phone: _____________________                     Mobile Phone: _____________________________

Business Phone: _____________________                     Email Address: ____________________________

Relationship to above: ___________________________
                                         Health Care/Medical Details

Medicare No: _________________ Private Health Insurance: Yes                                           No

                                                      Fund: ___________________

Private Doctor: ___________________________                              Phone: ________________

Address: ___________________________________________________

            __________________________________                           Post Code: ________

Private Dentist: ___________________________                             Phone: ______________

Address: ___________________________________________________

            _________________________________Post Code: ________

Certain medical conditions or previous injuries may influence your ability to participate in sport.
Examples of these include but are in no way limited to:

   Asthma                                                         Diabetes
   Allergies – including bee stings                               Epilepsy
   Spinal Injuries                                                Arthritis
   Previous Injuries

If you have any pre-existing conditions or any concerns about participating, we would encourage
you to seek medical clearance from your doctor prior to participating in sport.

Please detail below any pre-existing conditions and the treatment for these:




______________________________________________________________________________

GENERAL POLICIES:
   The club aims to provide a safe playing environment for its members
   Players are required to play in a safe manner according to the rules of the game and to follow instructions of
    coaches and officials.
   All players must wear the correct club uniform at matches – black socks (red & yellow hoops at top), black hockey
    shorts (no board shorts) or black sports skirt and club shirt. If wearing a cap it must be soft peaked and preferably
    black.
   Players and their families/friends are expected to represent the club in a positive manner consistent with our club’s
    values as a family based club.

                     To the best of my knowledge all information contained on this sheet is correct.
                                (If under 18 please have a parent or legal guardian sign)

        Signature ________________________                        Date ___________________
                                   SPONSORSHIP WANTED

Eastern Blades Hockey Club is always keen to hear from any prospective sponsors.

Please indicate on the Registration Form if you wish a Committee Member to contact you
regarding possible sponsorship.


       Yes I am interested in discussing sponsorship (please tick)


                                       2009 Fee Structure


Senior Rate                        $320.00 if paid before 16th May 09
                                   $340.00 if paid before 30th June 09
                                   $380.00 if paid after 1st July 09

Concession Rate                    $280.00 if paid before 16th May 09
                                   $300.00 if paid before 30th June 09
                                   $340.00 if paid after 1st July 09

Ladies playing Weekend & Vets      $580 if paid before 16th May 09
                                   $600 if paid before 30th June 09
                                   $640 if paid after 1st July 09

Casual Player                      $25.00 per game to a maximum of 10 games then the
                                   appropriate senior rate of $320 or concession rate of $280

Social Member                      $20.00


Fee Payment Attached: $ __________                   Date: ____/____/2009

Payment Method: Cash/Cheque

Receipt No: __________        Date Received: _____/_____/2009

PRIVACY STATEMENT

Eastern Blades Hockey Club abides by the relevant National Privacy Principles of the Privacy Act
1988. We are committed to protecting your privacy. Much of the information on this form is
sensitive information. Sensitive information will not be used for direct marketing purposes. The
information on this form is used for the purpose of providing us with the background as to your past
and present medical details. The types of organisations to whom we usually disclose this
information will be health care providers including sports trainers and first aiders but may also be
viewed by coaches, committee members and managers. We may also have to disclose it to our
professional advisers and insurers. If you do not provide us with any or all of the personal
information that we request then you may not be able to play in any of our teams. You can get
more information about the way we manage your personal information by writing to the President -
Eastern Blades Hockey Club PO Box 470 Morley WA 6943.
                              Senior Member’s Code of Conduct
1. Learn the rules of hockey and play by them.

2. Always act responsibly and avoid injury to yourself and others.

3. Never argue with an umpire or an official. If you have a problem, discuss it with your coach or
   manager and allow him/her to take the necessary action.

4. Control your temper. Verbal abuse of, or deliberate physical interference and aggression
   towards opponents will not be tolerated.

5. Respect the time and effort put in by your coaches, fellow players and other Club and
   Association officials. They deserve your support and full commitment.

6. Accept that when more than eleven players are named for your match, you may be required to
   spend time off the field as a substitute. When not on the field encourage your team and be
   prepared to play at all times.

7. Respect the equipment provided for your use. Hockey equipment is very expensive and should
   be used responsibly.

8. 100% attendance is required at both training and games. It is your responsibility to inform your
   coach or manager if you are not available for either.

9. It is expected that you will always be on time for training. You are also required to be at the
   game at least 30 minutes before the scheduled starting time to allow time to prepare for the
   game.

10. Wearing of correct uniform at all times is essential. According to the rules of the game you may
    not be permitted to take the field if incorrectly attired.

11. It is your responsibility to find out when and where you are playing each week and whether you
    have umpiring duties. If necessary, contact your respective Team Captain.

12. It is your responsibility to undertake your umpiring duties when rostered. Failure to do so will
    result in a fine and possible disciplinary action. Rules books and assistance will be available on
    request.

13. As a member of the Club you are required to fully participate in all fundraising activities.

14. You are encouraged to support your Club by watching other teams before and after your game
    and returning whenever possible to the clubrooms after Saturday matches.

15. When representing your Club you must do so in such a way as not to bring the Club into
    disrepute. This includes your behaviour at any Club or Association function, Carnival or
    Country trip, particularly when exposed to public scrutiny.

16. Any problems regarding selections or playing should be referred in the first instance to your
    Team Captain and then the respective Coaching Committee (Men’s and Women’s). Any other
    problems should be discussed with the Club President.

				
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