East Fremantle District

Willetton

          Junior Football Club

2006 REGISTRATION FORM

Please Circle Age Group            Auskickers    9’s    10’s    11’s    12’s    13’s    14’s    15’s    16’s    17’s

Were you registered with another club before?                    YES               NO

If Yes, Please state Club and last Year played:  ________________________________

NAME:

_______________________________________________________________________

ADDRESS:

_______________________________________________________________________

_______________________________________________________________________

DOB:

____________________

B/CERT NUMBER:

________________________

PHONE:

____________________

MALE     FEMALE

(Please Circle)

EMAIL:

_______________________________________________________________________

Would you like to earn money by Umpiring Junior Football (13 years and older)?      YES          NO

PARENT / GUARDIAN INFORMATION

NAME:

_______________________________________________________________________

ADDRESS:

_______________________________________________________________________

_______________________________________________________________________

Would you be willing to assist the club?

YES     NO

Please circle area of assistance

Coaching       Administration       Goal Umpiring       Time Keeping       Canteen      

Manager     First Aid       Runner       Social Committee       Fund Raising

Does your child suffer from any allergy, medical condition, or is he/she allergic to any medication?

YES      NO

DETAILS:

_________________________________________________________________

_________________________________________________________________

IN CASE OF EMERGENCY, PLEASE CONTACT:

NAME:

_______________________

PHONE: (Mobile pref.)

_____________________

In case of emergency, do you authorize the junior club to arrange any necessary treatment for your child, where prior notification has not been possible?              YES          NO

I would like to receive information regarding Junior Football from my local WAFL Club. 
YES           NO

Club Fees

The Willetton Junior Football Club is a division of the Willetton Sports Club (WSC).  All players in grades other than Auskick are required to be members of the WSC.  All player WJFC fees include trophies, team photos and some BBQs.

Current financial member of the Willetton Sports Club     YES   NO   (please circle)

If YES please show Membership Number ________________

Credit card details

Bankcard          Mastercard       Visa          Card number  ________  ________  ________  ________

Expiry _____ / _____  Amount $ _________ Name on card _________________________________

                                                           Cardholder’s signature _________________________________

PRIVACY POLICY

Personal information collected by Willetton Junior Football Club is for the primary purpose of membership requirements and/or competition purposes.  It will not be released for any form of commercial gain and will be maintained in a secure environment as per the requirements of the Privacy Act.  Completion and lodgment of this Registration Form indicates acceptance of the Club’s policy.

WAIVER AND INDEMNITY

‘Football’ -           Means Australian Rules Football

‘Club’ -                  Means Willetton Junior Football Club Division of Willetton Sports Club

‘League’                               Means East Fremantle District Football Development Council Inc.

‘Child’                   Means child or ward (whichever is applicable)

I am aware that playing Football, observing Football, learning to play Football and training to play Football, and participating in any activity carried out by the Club, are activities that inherently involve risk, and that in undertaking these activities my child does so at his/her own risk.

I am also aware that, as a condition of my child’s admission to membership of the Club, its office bearers, officials, coaches, managers, umpires, members, and/or agents are absolved from all liability arising from injury or damage howsoever caused.  That injury or damage may arise out of membership of the Club, playing Football, observing Football, learning to play Football and training to play Football, or negligence of any nature whatsoever on the part of the Club or League, their representatives, office bearers, officials, coaches, managers, umpires, members, and/or agents.

I understand and agree that nothing in this agreement purports to exclude any liability that may be owed by the Club or the League and their representatives pursuant to the provisions of any relevant Statutory Act/s covering these activities.  To the extent that any part of this agreement may contravene any of the Statutory Act/s I agree that part of the agreement may be severed and rendered void but the rest of the agreement will remain valid and continue to have effect.

I............................................................................of...........................................................do hereby acknowledge that of my own free will and desire, I have contracted with the Club for the instruction, training and playing of my child in Football and that I have read and understood the above waiver.

      ___________________________________________________________________                                  ________________________

                                    Signature – Parent/Guardian                                                                                          Date

OFFICE USE ONLY

Signed Club Official:

______________________________________             Date:

______________