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Busselton Hockey Stadium Club (Inc)
2015 Hockey Membership Form
Please complete and return no later than 28st MARCH 2015
Member Information ( * compulsory information)
Given Name(s)*:
Surname*:
Date of Birth* (___/___/_____):
Gender*:
Club/School:
Grade:
Age group?
YEAR PP-3
Male
Female
Team:
YEAR 4-6
YEAR 7-8
YEAR 9-12*
Please note Junior Grades have changed to school years. For players to be eligible to play in their Year Group they must
be of the correct age for that School Grade.
*Year 12’s can only play if not playing Senior Grades. If unsure ask your Club.
Which team/club did you play for in season 2014?
__________________________
Which team would you prefer to play for in 2015?
1.
MARGARET RIVER
Contact Information ( * compulsory information)
Address*:
Suburb*:
State*:
Postcode*:
Home Phone Number*: (08)
E-mail address:
Mobile Phone Number:
By providing your email address you agree to receive emails from the stadium from time to time
Parent/ Guardian information
Father Name:
Mother Name:
Mother Contact number:
Surname:
Father Contact number:
Emergency Contact & Medical Information
(This section is compulsory)
First Name:
Relationship:
Home Phone Number: (08)
Work Phone Number: (08)
Mobile Phone Number:
NB. At least one number must be provided
Medical Conditions/ Injuries:
Allergies:
PRIVACY COLLECTION STATEMENT
This information may be stored in part or in full on HockeyNet and may be used by the club, regional assoc, state assoc and/ or Hockey Australia. Any personal
information provided will only be used in accordance with the objects and purposes of HA, HA general business and in relation to HockeyNet. If the requested personal
information is not provided, you may not be able to receive the benefits of registration with the HockeyNet system. Individuals will be able to access their personal
information through HA upon reasonable notice. For further information on the HockeyNet Privacy Policy, please refer to www.hockeynet.org.au .
I give permission for my son/daughter to have their photo taken during hockey activities to be used for professional and promotional purposes.
MEMBERSHIP DISCLAIMER
By signing this form I agree to abide by the clauses and codes of behaviour that are contained in the Hockey Australia Member Protection Policy (MPP). The MPP can
be viewed at www.hockey.org.au . In consideration of my application for membership being accepted I acknowledge and agree that:
1.
Release and Indemnity: In consideration of the Club accepting my application for membership I, to the extent permitted by law:
a.
release and will release the Hockey Organisations 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 Hockey Activities; and
b.
indemnify and will keep indemnified the Hockey Organisations in respect of any Claim by any person arising as a result of, or in connection with, my
membership and/or participation in any Hockey Activities.
2.
I will be bound by and agree to comply with the constitutions, regulations and policies of the Club.
3.
I acknowledge that I am exposed to certain risks and that accidents can happen, which may result in me being injured, or my property being damaged.
4.
I declare that I am medically and physically fit and able to participate in any Hockey Activities. I will immediately notify the Club of any change to my medical
condition, fitness or ability to participate.
Signature (Member):
Date:
If under 18 Signature of Parent/ Guardian:
Date:
Please return to the Margaret River Hockey Club via your Team Manager
or E: [email protected]
Carnival and Championship Nomination Information 2015
Please tick the appropriate box for all carnivals/championships that you may like to nominate for in 2015
Please note Nomination closing dates and trial information will be on the website
www.busseltonhockey.org.au
Smarter Than Smoking Club Championships – Perth Hockey Stadium (PHS)





J 7/8
J 7/8
J11/12
J9/10
J9/10


Boys
Girls
Boys & Girls
Boys
Girls
6-8 July
8-10 July
15-17 April
13-15 July
15-17 July
Approximate Cost $100 plus accommodation in Perth
Please note players are responsible for finding their own accommodation
Rockingham Junior Carnival – Rockingham Hockey Stadium
Dates & Grades TBA
o Girls
o Girls
o Girls
 J5/6
 J7/8
 J9/10


o Boys
o Boys
o Boys
Usually a one day Carnival
Cost TBC
South West Junior Hockey Championships – Bunbury Hockey Stadium
30TH May – 1ST June
o Girls
o Girls
o Girls
 5/6
 7/8
 9/10

o Boys
o Boys
o Boys
Approximate Cost $50
Other Important Information - please tick & sign
o I, Parent/Guardian have read the Carnival/Championship Guidelines on the Busselton Hockey
website and acknowledge that they understand and agree to abide by rules/conditions as set by
Busselton Hockey Stadium.
___________________________
Name of Parent/Guardian
___________________________
Signature of Parent/Guardian
___/___/___