2015 Player Information
PLEASE NOTE - One form is required for each player.
Player’s Surname:
___________________________________________________
Player’s Given name:
___________________________________________________
Date of Birth:
________________
Male / Female
________________ Registering for: Under ______________
(based on age as at 31 December 2015)
Address:
___________________________________________________
Suburb:
_________________________ Post Code: ________________
Phone:
_________________________ Mobile: ___________________
Email:
___________________________________________________
Name of family contact: ___________________________________________________
Relationship to player: ___________________________________________________
Player was last registered with______________________________________ (Club) playing
in Under ____________ in the 20__________ season.
(Please note players registered with a different Club or Association in 2014 will need to advise
the Club via email they require a transfer, which are completed online by the Club).
Medical Conditions
Do you have any medical condition/s that the club needs to be aware of? YES / NO
If yes, provide details/recommended treatment:
______________________________________________________________________
______________________________________________________________________
_______________________________________________________________________
School attended: ________________________________________________________
Friends in Club/Team request ______________________________________________
We will endeavor to keep your child with their friends or preferred team, but please be aware
that this may not always be possible.
2015 Parent Consent
This form must be signed by a parent or guardian.
Player’s Name:
_____________________________________________________
Parent’s Name:
_____________________________________________________
I give consent for the information provided on the Player Information form to be used by
Dominoes for club purposes.
I give consent for photographs of my child taken whilst participating in Dominoes Basketball
Club activities to be used for promotional purposes, including publication on the Club’s
website and social media sites.
I accept responsibility for the payment of Registration Fees due to Basketball Tasmania and
to Dominoes Basketball Club and that they must be paid as and when they fall due.
I accept responsibility for reimbursing the club should any item of equipment (including
playing uniform) be lost or damaged whilst allocated to the above player.
I understand that I will be required to assist with bench duties over the season as requested
by the coach.
I am willing to assist the club with any fundraising activities or events that require volunteers
throughout the 2015 season. YES / NO
(please circle)
Signed: _______________________________________________________
Dated this _____________ day of ___________________________2015.