Longford Cricket Club Registration Form

Surname...........................................Given Names.......................................................................

Address.........................................................................................................................................

Phone.................................E-mail.................................................................Mobile....................

Date of Birth.....................................................School & Yr.........................................................

List previous playing history.........................................................................................................

Additional information required for players under 18 years of age:

Mother/Guardian...............................................Phone..............................Mobile.......................
Father/Guardian.................................................Phone..............................Mobile.......................

Assistance and Support:/Please circle your areas of interest.

Coaching Managing Scoring Umpire

Administration Occasional Help Sponsorship (Team/General)

Note Child Protection: Any coach, manager or those giving regular assistance are required. by law, to sign a
Child Protection Disclosure Form.

Accident and Injury Disclaimer: Longford Cricket Club is insured to carry out coaching of both Youth and
Senior players in rented facilities, this insurance covers the Club for Public Liability only and the club takes no
responsibility for injuries experienced by players at any training sessions, trips or games. Players are advised to
take out a Personal Liability cover which will be totally separate from the Club. I also give my permission to the
The Club to arrange medical attention that may be deemed necessary, including ambulant transport and I agree to
pay for all such costs incurred.

Agreement: I hereby apply (for my child) to be registered as a player of The Longford Cricket Club. (I) (my
child) agrees to abide by the rules of The Club's constitution, by-laws and policies.

Privacy: Unless otherwise notified, I agree to my child's name/photo being published in Club Newsletters, Club
Website and Newspapers for the purposes of acknowledgment & commendation only.

Signature...........................................(Must be co-signed by parent/guardian if under 18 years of age)

The Club reserves the right to accept or decline any registration at any time during the competition
year. (Registration will not be accepted without payment of fees and is subject to team availability).

Date fees paid....................................Amount...............................Receipt No....................................

Membership Fees 2011

Development Fund / Sponsorship: all amounts welcome

Student Є50 Adult Є70 Pavilion Є30