Get EASTERN MAVERICKS DISTRICT BASKETBALL CLUB INC

EASTERN MAVERICKS DISTRICT BASKETBALL CLUB INC. ABN 77 564 054 746 P. O. Box 1461 Mount Barker SA 5251 Version 2016/2017 JUNIOR PLAYER INDEMNITY FORM and MEDICAL INFORMATION Team Manager to hold form in the team folder In consideration of the Eastern Mavericks District Basketball Club Inc. here in after called The Club selecting name of Under Girls / Boys here in after called the player as a member of the club s contingent to participate in matches training sessions or functions. In addition I also authorise any Officer servant or agent of the club to obtain any medical/hospitalization treatment deemed necessary which will be at my expense provided I have been notified as soon as practicable thereafter. No Liability or responsibility is accepted for errors or omissions or for loss or damage suffered as a result of a person or club acting on this indemnity. PLAYER INFORMATION Players Name D. O. B / / Home Phone Home Address Suburb Postal Address if different from above Doctors Name Medicare No Private Health Fund Ambulance Cover Gender Mob M/F State Postcode Phone Number YES / NO Medical Condition Epilepsy Fainting / dizzy spells Heart Condition Diabetes Ear Disorder drainage tubes/deafness Allergies bee stings peanuts etc Respiratory Disorder Sports Injuries Does your child require an inhaler Mouth Guard Contact Lenses Other medical information Membership No. Circle Further Information Yes / No Yes / No Colour Brand Please list Photography Filming Recording Declaration Eastern Mavericks District Basketball Club may take photographs film or audio record of players during games including Scheduled weekly matches Carnivals SA Country or Metropolitan team games The Eastern Mavericks District Basketball Club may display these photographs films and recordings to promote the Eastern Mavericks Basketball Club on Social Media sites including the Eastern Mavericks Website Face Book Local Newspapers Promotional Material Publications or Newspapers. I DO give permission for my child s photograph film or audio recording to be use in the above form to promote Eastern Mavericks. PLAYER INFORMATION Players Name D. O. B / / Home Phone Home Address Suburb Postal Address if different from above Doctors Name Medicare No Private Health Fund Ambulance Cover Gender Mob M/F State Postcode Phone Number YES / NO Medical Condition Epilepsy Fainting / dizzy spells Heart Condition Diabetes Ear Disorder drainage tubes/deafness Allergies bee stings peanuts etc Respiratory Disorder Sports Injuries Does your child require an inhaler Mouth Guard Contact Lenses Other medical information Membership No. Circle Further Information Yes / No Yes / No Colour Brand Please list Photography Filming Recording Declaration Eastern Mavericks District Basketball Club may take photographs film or audio record of players during games including Scheduled weekly matches Carnivals SA Country or Metropolitan team games The Eastern Mavericks District Basketball Club may display these photographs films and recordings to promote the Eastern Mavericks Basketball Club on Social Media sites including the Eastern Mavericks Website Face Book Local Newspapers Promotional Material Publications or Newspapers. I DO give permission for my child s photograph film or audio recording to be use in the above form to promote Eastern Mavericks. I DO NOT give permission for my child to be photographed filmed or audio recorded SIGNED EMERGENCY CONTACT INFORMATION Name Email DATE / / Relationship Work DECLARATION I declare the above information is true and correct WITNESS NAME The above information is confidential and will only be used by the Eastern Mavericks District Basketball Club Incorporated in the administration and subsequent operations of the Club. I hereby give my consent to the player participating in club matches training sessions and functions. No Liability or responsibility is accepted for errors or omissions or for loss or damage suffered as a result of a person or club acting on this indemnity. Iof hereby undertake to indemnify the Club its officers servants agents or anyone of them against all damages claims or demands which may be made against them or any one of them in respect of or arising out of the participation of the player for the Club whet her such claim be made by on or on behalf of the player or any other person. I also agree that the Club its officers servants and agents shall be free and clear of all responsibility to me or any other person whatsoever for any accident or illness of the player during his/her participation for the Club.