BUNBURY CARNIVAL NOMINATION
Nomination fee of ……………
COMPLETE AND RETURN TO OFFICE WITH PAYMENT or COPY OF BANK RECEIPT FROM DIRECT DEBIT
Tick relevant age group for team selection.
GIRLS
5-6 (11)
7-8 (13)
9-10 (15)
BOYS 5-6 (11)
7-8 (13)
9-10 (15)
Players Name
Date of Birth
School Year
Parent/Guardian Name(s)
Postal Address
Email Address
Contact Numbers
Home
Work
Mobile
Club
Preferred Position(s)
1.
2.
Permission to use player photo
Yes
No
GOALIES - DO you have your own or club gear to wear?
Yes
No
Uniform Requirements
Shirts supplied. GIRLS/BOYS size
S
M
L
SUPPORT is always required. Please complete if you wish to volunteer for any position.
Name
Contact Numbers
COACH
MANAGER
UMPIRE
SOUTH WEST CARNIVAL CANTEEN
Mainly Food Preparation e.g. Rolls, Sandwich’s, etc.
Yes
YES
YES
SAT 7.00AM – 9.00AM
SUN 7.00AM – 9.00AM
MON 7.00AM – 9.00AM
SAT 11.00AM – 1.00PM
SUN 11.00AM – 1.00PM
MON 11.00AM – 1.00PM
SAT 1.00PM – 3.00PM
SUN 1.00PM – 3.00PM
CONSENT & INDEMNITY FORM
Strictly Confidential
PLAYERS NAME:
ADDRESS:
Emergency Contact:
AGE GROUP (tick)
5-6 /U11 ( )
7-8/U13 ( )
9-10/U15 ( )
11-12/U17 ( )
Medical Details
Name of Family Doctor
Telephone No
Medicare Number:
Private Cover Number – HBF/Medibank/Other
Ambulance Cover
No(__)
Yes(__)
Is your child subject to seizures, fainting, diabetes or any other condition that may affect their safety
No
(__)
Yes
(__)
If yes please give details
MEDICATION: Parent/guardians are request to make arrangement with the Team Manager for the safekeeping
and handling of medications prior to the Carnival
Is your child presently taking tablets and/or other forms of medication?
No
(__)
Yes
(__)
If Yes, Does your child self-administer the medication:
No
(__)
Yes
(__)
Name of medication,:
dosage
Frequency of use
Is you child Allergic to
Penicillin
(__)
Any other Drug
(__)
Any Food
(__)
Other
(__)
Date of Last Tetanus vaccination:
Please give details
(if not sure write unknown)
Other Information: Please provide any other information about your child, which will enable Organisers of the Carnival to provide care
of your child.
PARENT / GUARDIAN CONSENT
Photographing – The Association may wish to publish images of your children aged under 18 to promote Hockey and the Smarter Than
Smoking Message. The publishing of your childs image will be appropriate sporting dress with the focus on the activity of the player rather
than the particular child. If you DO NOT wish to have your childs photograph displayed in public places - TICK this box – { }.
Your child voluntary accept all the risks and danger of participating and abide by all the decisions and rules pertaining to the aspects of duty
of care and responsible behaviour.
I am aware that any costs incurred as a result of accident or illness are my responsibility and that Organisers are not responsible for any loss
or damage to my child's personal property that may occur during the course of the carnivals.
I agree to inform the organiser before the schedule carnival of any changes to the above information, so the appropriate arrangements may be
prepared. I acknowledge that, should it be necessary, Organisers will arrange to present my child for medical assessment and treatment.
The success of Carnivals is built on the foundation of its participants. Players must be willing to participate, trust, and communicate with
each other in order to create a positive experience. The Committee reserves the right to dismiss any players who is seen as being a detriment
to the group and is a safety risk or medical concern. The use and /or possession of tobacco, non-prescription drugs or alcohol is strictly
prohibited. Any of these situations will result in the player being removed and transported back home at their own expense. No refund will
be given.
I hereby indemnify the Bunbury Junior Hockey, the individual organisers of the carnival and all other connected herewith, from any claims
whatsoever which may arise from my child's participation in the team. I will abide by all the decisions and rules pertaining to the aspects of
due care and responsible behaviour.
PLAYERS SIGNATURE
PARENT/GUARDIAN SIGNATURE
DATE