2013 Junior Cricket Registration Form - Queensland Cricket

Bulimba Cricket Club Incorporated(Est. 2010)Affiliated with the Queensland Cricket Association,Eastern Districts Junior Cricket Association and theBayside East and Redlands Cricket Association (BEARS)Address Correspondence to: Bulimba Cricket Club, PO Box 36 Bulimba Qld 4171www.bulimbacricket.com.au2012 – 2013 Junior Cricket Registration FormPLAYER INFORMATION:Surname: __________________________________ First Name:__________________________ Middle Name:________________Address: ________________________________________________________________________________Postcode:__________Home Phone No: ________________________ Date of Birth: / /The player is available to play for Half or Full Season? School attending before Christmas:__________________________Current Year Level: ______________School attending after Christmas (if different): ____________________________PARENTS/GUARDIANS INFORMATION:Names: (Mother) ___________________________________________ (Father) _________________________________________Occupations: (Mother) _____________________________________ (Father) ___________________________________________Mobile Phone No(s): (Mother) __________________________________ (Father) ________________________________________Email Address: (Mother) _____________________________________(Father) __________________________________________REGISTRATION FEES:FOR U9 TO U13 PLAYERS:I wish to play Under________I wish to play with player(s) or coach__________________________________________________ Full Season $180 Half Season $150 I wish to purchase a club shirt $40 SIZES: 6 8 10 12 XS S M L XLPLEASE NOTE: Players are required to wear the Bulimba Cricket Club shirt for all matches and other events. Due to BEARSrequirements, this fee is mandatory for those playing Under 13. I wish to purchase a replacement club cap $15 ONE SIZE FITS ALLFOR IN2CRICKET PLAYERS: in2CRICKET including Starter Pack $90 ~ I require a size 6 8 10(Starter Pack includes Backpack, Shirt, Water Bottle, Bucket Hat and Bat)OR in2CRICKET without Starter Pack $45PLEASE NOTE: in2CRICKET Players must wear the official Milo in2CRICKET hat and shirtPAYMENT:The total amount payable is $ _______. I am paying by:Cash Cheque Direct Deposit - Bulimba Cricket Club IncorporatedSuncorp BSB: 484 799Account No: 203460002Reference: Child’s Surname, First NamePlease send an email to secretary@bulimbacricket.com.auonce you have performed the transfer of funds to the Bulimba A/c.MajorSponsorSilverSponsorBronzeSponsors

Bulimba Cricket Club Incorporated(Est. 2010)Affiliated with the Queensland Cricket Association,Eastern Districts Junior Cricket Association and theBayside East and Redlands Cricket Association (BEARS)Address Correspondence to: Bulimba Cricket Club, PO Box 36 Bulimba Qld 4171www.bulimbacricket.com.auOUR CLUB NEEDS YOUR HELPThe Bulimba Cricket Club provides the development of cricketing skills, teamwork and sportsmanship for boys and girlsaged 5 to 12 years of age in a positive and friendly environment. The club is run entirely on voluntary help from parentsand guardians. We provide coaching, managing, umpiring & score keeping opportunities to parents and guardiansalong with assistance for those that require it. Your help is great appreciated so please indicate in the boxes below ifyou are able to assist us with the following:Team Coach Team Manager Assist at trainingUmpiring at matches Scorer Supervision at matchesin2CRICKET Coach Assisting with in2CRICKET on Friday NightsAUTHORISATION:PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNINGI, _____________________________________ am a parent or legal guardian of _____________________________ .I agree to my child applying to and being allowed to participate in the activities of the club and associations (QueenslandCricket, Eastern Districts JCA & BEARS CA). In consideration of the club and associations allowing my child to take partin cricket, I acknowledge, agree and confirm the following:(a) That there are inherent risks associated with Cricket Activities (the activities) which may result in my child beinginjured including in a serious manner. I fully accept and agree to bear those risks in my own right and on behalf of mychild.(b) To the full extent permitted by law I agree both on behalf of my child and in my own respective rights to absolve,indemnify, release and discharge the Bulimba Cricket Club and its officers, employees, representatives and agents (“theIndemnities”) from any and all liability for any injury, loss or damage to my child however caused arising out of mychild’s participation in the activities, including without limitation, as a result of acts of negligence by the indemnities.(c) I consent to Bulimba Cricket Club promoting youth in cricket by publishing photographs of my child participating inthe activities for the club in brochures, newsletters or on the web page of the club.In addition, I hereby agree and consent to the provision of the personal information regarding my child as set out in thisform to the Queensland Cricket Association Limited for use by them in the course of the administration of cricket inQueensland, including registration and insurance of players.I have read, understood, acknowledge and agree to all the matters referred to in this statement, including the warning,release and indemnity.Signed______________________________________________________Date____________________________PLEASE EITHER (A) POST BOTH PAGES WITH YOUR PAYMENT TO CLUB SECRETARY, BULIMBA CRICKETCLUB, PO BOX 36, BULIMBA QLD 4171 OR (B) EMAIL BOTH PAGES ALONG WITH YOUR DIRECT DEPOSITCONFIRMATION DETAILS TO secretary@bulimbacricket.com.au_______________________________________________________________________________________________Office Use Only –Paid - $__________ Date Payment Received - ______________Receipt Number - ____________________MajorSponsorSilverSponsorBronzeSponsors