Eastside activity centre

EASTSIDE ACTIVITY CENTRE

REGISTRATION FORM 2016

ATHLETES NAME:________________________________________________
DATE OF BIRTH: ______________ TODAYS DATE:____________
ADDRESS:___________________________________suburb:___________________Postcode__
EMAIL ADDRESS:_________________________________________________
HOW DID YOU HEAR ABOUT THE CLUB? ___________________________
HAS THE ATHLETE BEEN REGISTERED WITH ANOTHER CLUB IN 2015?
□ YES ( CLUB NAME)______________ will you be continuing with that club and EAC in 2016 ?

yes /no.

Multi club athletes, Please note if you train at EAC and wish to compete you need to compete as a member of EAC.

□ NO
PARENT/GUARDIAN DETAILS:

NAME/S: _______________________________________________

TELEPHONE CONTACT DETAILS;

HOME:_________________________ BUSINESS:_____________________

MOBILE:_______________________

ARE THERE ANY CUSTODY ARRANGEMENTS OF WHICH WE SHOULD BE AWARE? Y/N
IF YES PLEASE PROVIDE RELEVANT DETAILS;_________________________

BY BECOMING A MEMBER OF Eastside activity centre I agree that photos of my child maybe used on Facebook and other promotional material. ____________ ( please sign if you are unable to sign please see the manager)

EMERGENCY CONTACT:

NAME:_____________________________________________PHONE:_________________

DOCTORS NAME:___________________________________PHONE:_________________

ADDRESS:__________________________________________________________________

ANY MEDICAL CONDITIONS THAT MAY AFFECT ATHLETE ( PLEASE ATTACH ANY FURTHER INFORMATION IF REQUIRED)_________________________________

MEDICATION/ TREATMENT:_______________________________________________

Are you: Aboriginal Torres strait islander

Please read each of the following statements and initial to indicate you understand and agree.

I HEREBY CONSENT TO ______________________________________ PARTICIPATING IN ALL CLUB ACTIVITIES. I UNDERSTAND THAT EVERY ENDEAVOUR WILL BE MADE TO CONTACT ME PRIOR TO ANY MEDICAL ATTENTION BEING GIVEN. WHERE IT IS NOT PRACTICAL TO CONTACT ME, I HEREBY AUTHORISE THE DESIGNATED REPRESENTATIVE OF EAC TO SEEK MEDICAL INTERVENTION (INCLUDING TREATMENT, EMERGENCY TRANSPORT, HOSPITALISATION, ANAESTHESIA AND MEDICATION) IN THE EVENT OF ANY ACCIDENT, MISHAP OR ILLNESS DURING MY CHILDS PARTICIPATION IN THE PROGRAM THROUGHOUT THE YEAR. __________
I UNDERSTAND THAT THESE SERVICES WILL BE SOUGHT AT MY EXPENSE AND AS DEEMED NECESSARY AND/OR APPROPRIATE BY THE COACHING TEAM OF EAC.

I AGREE TO ABIDE BY ALL POLICIES AND PROCEDURES OF EAC INCLUDING THE FEE POLICY. ___________

I UNDERSTAND THAT EVEN THOUGH ALL EFFORTS HAVE BEEN MADE TO ENSURE A SAFE ENVIRONMENT AS WITH ALL SPORTING PURSUITS THERE IS A RISK OF MINOR AND/OR MAJOR INJURY. ______________
All fees are to be paid upfront for each term. _____________
Fees are non refundable _________________.
If you do not wish to continue classes you MUST inform the club in writing otherwise you will continue to receive accounts as a coach will be allocated until an official cancellation has been received at least two weeks prior to the end of term, if you decide to stop during the term for reasons other than medical then fees are non refundable._______

PRINT NAME:______________________________

SIGNED:__________________________________ ( PARENT/GUARDIAN)
DATE:_____________________________

OFFICE USE ONLY:
Entered on accounts database

Registration paid

Entered on GOL

Email added to database

Ready to be filed