Southport Labrador Cricket Club PLAYER'S REGISTRATION FORM 10 11 12 13 14 15 2012/13 17 SENIOR TEAM / AGE GROUP FIRST NAME SURNAME ADDRESS P/CODE PHONE # (Home) MOBILE # E-MAIL ADDRESS D.O.B PREVIOUS CLUB Clearance Obtained? (new players only) YES NO YES NO YES NO REPRESENTATIVE CRICKET Are you interested in playing junior representative cricket? (if yes, your club will provide you with more information) Are you AVAILABLE to play senior representative cricket?(Webb Shield & Plunkett Cup) (if you select YES, are selected to play and subsequently withdraw from a match then you may face suspension imposed by Cricket Gold Coast) PLAYER'S SHIRT SIZE Junior Mens 10 12 14 S M L XL XXL XXXL INSURANCE: Injury cover (including Non-Medicare Medical, Capital Benefits and Loss of Income) is provided under the National Club Insurance Program, managed by JLT Sport. Details of this insurance are available at www.jltsport.com.au, or by contacting a representative of the Club. I indemnify and shall keep indemnified the club and its representatives from any claim relating to any injury suffered by myself or child/guardian or members of my family in the course of participation in club activities. PLAYER'S SIGNATURE DATED (for players over 18 years of age) PARENT'S SIGNATURE DATED (for players under 18 year of age) By signing this form I agree to the terms & conditions in the insurance indemnity printed above. I acknowledge that I have read & understood the Cricket Gold Coast Code of Conduct & I agree to abide by its terms & conditions. I support the Club in its undertakings & accept the Club will take any necessary disciplinary actions against any player, parents & spectators for repeated or serious breaches of these Codes of Conduct. JUNIORS ONLY PARENT'S NAMES SCHOOL ATTENDED VOLUNTEER INFORMATION The club needs volunteers to help run it's cricket programs - please tick any boxes you can assist with coaching junior cricket coaching senior cricket scoring team manager umpiring general committee game day set up / pack up bar / canteen staff fundraising / events OFFICE USE ONLY Cash Date Paid Cheque Eftpos Receipt No Amount Paid $ Signed Payment of Season Fees ANNUAL FEES: Payment can be made by cheque, money order or cash. *Do not send cash in the mail. 1 Player Only $225.00 Fees include playing cap,Team photo and end of season trophy. 2 Players from the one Family $350.00 Additional player from the same family $110.00 each each Milo In2 Cricket $85.00 Training Shirts $30.00 Training Shorts $27.00 All new Players to the Club are given a shirt FREE OF CHARGE (excluding Milo Kids) A deposit needs to be paid before the child can take to the field on the first match. If payment arrangements are required please do not hesitate to contact our Treasurer. Membership Conditions 1 In Consideration of my/our child being allowed to participate in cricket matches, training and associated events ("Activities") organised and/or supervised by the Southport Labrador Cricket Club - Juniors (Association), I/we hereby acknowledge, agree and confirm the following: a) There are inherent risks associated with the Activities that may result in personal injury (even of a serious nature) to participants. I/we fully accept and agree to bear these risks. b) I/we understand that should personal injury occur to my/our child that they will not be covered by the Associations Insurance unless my fees are paid in full. c) To the full extent permitted by law, I/we absolve, release, discharge and indemnify the Association, its Officers, Employees Representatives and Agents ("Indemnitees") from any and all liability for any injury, loss or damage suffered by my/our child however caused arising out of my/our child's participation in the Activities, including without limitation, where caused by any act of negligence by the Indemnities. d) I/we have read, understood, acknowledge and agree to all the matters referred to in the statement including the warning, release and indemnity. 2 I/we acknowledge and agree that the personal details relating to my/our child set out on this form, including without limitation my/our child's name and address, may be provided to the Queensland Cricket Association Ltd, Cricket Gold Coast Ltd and the Gold Coast & District Junior Cricket Association for use by those organisations as they see fit in the course of their administration of Cricket in Queensland. 3 I/we will abide by the Association's Constitution and the District's code of conduct at all times. I/we acknowledge that no tolerance will be accepted of any physical or mental abuse towards any other Player, Manager, Coach, Umpire, Club Official or District Representative in way shape or form. 4 I/we agree to fulfil my/our obligations to the Association by paying in full all membership fees owing to the Association as and when they fall due. 5 I/we acknowledge, confirm and agree that I/we have read the above conditions and accept them in full. SIGNATURES: PARENT(S) NAMES PARENT(S) SIGNATURE