TEAM NAME/ TWO NOMINATED CONTACTS Team name: Contact name 1: Contact name 2: Suburb: Postcode: Telephone (H): Mobile: Email: Suburb: Postcode: Telephone (H): Mobile: Email: How did you hear about this program? Friend Website Social Media Advertising Leisureplex Other (please specify) Please tick if you do NOT want to receive offers, program and event information from Karratha Leisureplex SELECT SPORT YOU WISH TO NOMINATE FOR *Please check brochure for details on days and times* Ladies Social Netball (TUES) Mixed Social Netball (THURS) Mixed Indoor Soccer (Futsal Rules) (TUES) Mixed 5-a-Side Beach Volleyball (FRI) IF grading is required please select preferred division: Div. 1 Div. 2 *Please note that new players are welcome throughout the season but the Leisureplex reserves the right to disallow teams to introduce new players that are deemed to increase their strength beyond the level of the division in which the team is playing* PLAYER DETAILS NAME EMAIL CONTACT NUMBER UMPIRE (Y/N) *NOMINATE AT LEAST TWO PLAYERS** Page 1 of 5
ADDITIONAL PLAYERS Does your team require additional players? Yes No If YES, how many? UNIFORM DETAILS Shirt colour Skirt/Shorts Colour Bib/Number Colour INFORMATION, TERMS AND CONDITIONS Players must be a minimum of 16 years of age to participate. All nomination forms and fees must be complete and paid in FULL by the dates above before a team can participate in the competition. New players are welcome throughout the season as long as they are registered before their first game. All sign on sheets and game fees must be completed by all players and paid respectively before the commencement of a game. Causing a match to forfeit will incur the loss of the team nomination fee and therefore the team will not be in credit for the final game of the season. Team members are responsible for reading the Rules and Regulations document specific to their chosen sport. This document will be emailed to team contacts and made available at the Karratha Leisureplex Fixtures will be emailed to contacts and displayed, along with results and ladders at the Karratha Leisureplex. Teams are expected to play under the general principles of fair play and good sportsmanship. Failure to do so may result in penalties to a player and/or team. Any injuries sustained during a game must be reported to centre management and a Visitors Accident Form must be completed. Any issues involving an umpire decision can be addressed during a break or at the completion of a game by the team contact/captain only or by contacting Karratha Leisureplex management. The Karratha Leisureplex holds the right to suspend or disqualify a team and/or player from the competition if their behaviour is deemed unacceptable by management. FEES AND DATES NOMINATE BY: Friday 18 th July NOMINATION FEE: $60 (This is the equivalent to one (1) game fee to be paid when nominating a team and must be maintained throughout the season. This will mean the last game will be paid for. This is a non-refundable amount should the team withdraw from the competition) STARTS: The week of July 28th 2014 DAY AND TIME: PRICE PER GAME: See timetable for specific playing day and fixtures will be distributed after registration. Netball and Indoor Soccer $60 per team Mixed Beach Volleyball $35 per team + Individual Pool Entry ($5.70) Page 2 of 5
Page 3 of 5
UMPIRING DUTIES As you are aware, games are unable to be played in a fair and just manner without sufficient umpires. The following will be expected of each team in respect to umpiring duties: Teams will be rostered on to umpire equally throughout the season and as often as the number of teams in the competition dictates. It is the team s responsibility to organise umpires for duty and failure to do so, or notify the KARRATHA LEISUREPLEX at least 24 hours in advance may result in a fine or deduction in points. Please indicate on the nomination form, AT LEAST TWO players who are able to umpire throughout the season and their names will go onto a contact list in case of an emergency. All umpires will be paid for their duties. DECLARATION *Please ensure you have read and completed the entire form before signing the declaration* In signing this form, we, on behalf of all members, have the authority to declare that (team name) understands that: We have read and shared the INFORMATION, TERMS AND CONDITIONS with all members. We are aware that personal injuries may arise directly or indirectly from sport and participation is at own risk. We take full responsibility for my personal property and may not hold Karratha Leisureplex responsible for any lost or stolen items. Photographs of team members may be taken and used by the Karratha Leisureplex for promotional purposes. We understand and accept the rules of competition and any consequences that may be incurred for failure to comply with these rules (as outlined in the Leisureplex Rules and Regulations document) *Note: Having completed this declaration it is your responsibility to ensure that you have a copy of the Rules and Regulations of your nominated sport. Contact 1 Signature Print Contact 2 Signature Print *Note: Having completed this declaration it is your responsibility to ensure that you have a copy of the Rules and Regulations of your nominated sport and that ALL players are aware of them. Page 4 of 5
PAYMENT DETAILS AMOUNT: PAYMENT TYPE: CASH CHEQUE CREDIT CARD: CREDIT CARD: VISA MASTERCARD CARD NUMBER: NAME ON CARD: EXPIRY DATE: CCV#: SIGNATURE: Return completed form to the Programs Department: Post: PO Box 219 Karratha WA 6714 In person: Dampier Highway opposite Broadhurst Road Email: teilah.walker@roebourne.wa.gov.au OFFICE USE ONLY Receipt Number: Amount Paid: Date Paid: Received By: Method of Payment Cash Cheque Eftpos Purchase Order (Purchase order # ) Page 5 of 5