Application Form

 

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Caboolture Disability Indoor Cricket Inc.

ABN: 73 064 864 251

Phone: 0415 271 919

Email: info@disabilityindoorcricket.com.au

Website: www.disabilityindoorcricket.com.au

 

The information supplied will be kept confidential and secure, and will only be used to provide necessary aid in the event of an emergency or medical situation.  We ask that you assist us by keeping this document up to date.

 

Player:

 

Name: _______________________________________________ Date of Birth: _____________________

 

Address: ______________________________________________________________________________

 

_____________________________________________________ Phone No: _______________________

 

Emergency contacts:

 

Name: _______________________________________________ Phone no: ________________________

 

Doctor’s Name: ________________________________________ Phone no: ________________________

 

Doctor’s Address: _______________________________________________________________________

 

Any Medical or Physical Restrictions: __________________________________________________________

 

________________________________________________________________________________________

 

Any relevant information for the coach to ensure the sporting experience is an enjoyable one for the player, e.g. skills, communication needs, understanding any likely behaviours , etc

 

________________________________________________________________________________________

 

________________________________________________________________________________________

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Caboolture Disability Indoor Cricket Inc.

ABN: 73 064 864 251

Phone: 0415 271 919

Email: info@disabilityindoorcricket.com.au

Website: www.disabilityindoorcricket.com.au

 

Player’s name and/or photo may be used to inform members of activities, or to promote Caboolture Disability Indoor Cricket, Inc., in the following media.

Yes                         No                          Our Website.

Yes                         No                          Our Facebook Page

Yes                         No                          Local Newspaper.

Yes                         No                          Media distributed to Disability Centers and Schools.

 

If player will be attending sporting activities without support, either at Indoor Sports Centre or Social Events, please attach a list of any medications with Doctor’s instructions, as well as a current Medical Action Plan.

I give permission for first aid to be administered, and to call an ambulance for transport to hospital if required.  I acknowledge that there is no player insurance at venues, hence there will be no claims or compensation for injury against Caboolture Disability Indoor Cricket, Inc., and committee members.

 

Signature of Player/Guardian: _____________________________________________________________

 

If player under 18

Signature of Parent/Guardian: _____________________________________________________________

If the player will be transported by parent/s or support person/s to and from the sports or social venues, and they may not be staying, please provide contact details for them.

 

Name: ___________________________________________

Mobile Phone no: ________________________

 

Name: ___________________________________________

Mobile Phone no: ________________________

 

Support persons are welcome to stay and watch, or even provide appropriate support on the court if desired.