Membership Registration Form

Emergency Contact

Emergency Contact Name *

Relationship

Emergency Contact Address

Emergency Contact Phone

Emergency Contact Mobile *

Medical Information

Medicare Number:

Number on Medicare card:

Ambulance Cover?

Yes

Ambulance Membership Number

Private Health insurance

Yes

Name of Health Fund

Health Fund Member Number

Family Doctor

Doctor's Phone Number

Doctor's Clinic Address

Existing Medical Conditions*

Do you have a treatment plan for any stated medical conditions?

Yes

Please attach your treatment plan if required

Choose File

I authorise the coach/manager/club member to provide me/my child with medical treatment and/or the use of an ambulance if deemed necessary...

Yes

I/my guardian, will take responsibility for all necessary emergency medical costs, including ambulance.

Yes

Player/Guardian Name *

Date *

Image Capture and Usage

Image Capture

I give permission for myself/my child to be photographed while at hockey clinics, games, activities, fundraising events and training sessions.

Yes

Image Use

I also give permission for the publication of my/my child’s image on the Wangaratta Hockey Club website, in social media, in the newspaper, in the Club’s newsletter or on Club promotional flyers and brochures.

Yes

Code of Behaviour

All members and supporters of Wangaratta Hockey Club will show fairness, a competitive spirit and sportsmanship to team members, coaches, managers, other players and spectators. For Juniors, there is a strong focus on participation, encouragement, enjoyment and skill development.

Please read Hockey Australia's player Code of Behaviour, below, before proceeding:

Player Code of Behaviour

Behave in a sporting manner at all times to all players, officials and spectators.
Don’t make detrimental statements in respect of the performance of any match officials or umpires.
Play by the rules at all times and ensure that the game of hockey is not brought into disrepute by your actions.
Do not engage in inappropriate and/or physical contact with players or officials during the course of play.
Accept responsibility for all actions taken. Exercise reasonable care to prevent injury by ensuring that you play within the rules. Reasonable care consists of showing due diligence in abiding by the rules and adhering to the officials decisions.
Adhere to the Anti‐Doping Policy advocated by HA.
Do not bet on the outcome or on any other aspect of a hockey match or competition.
Do not try to achieve a contrived outcome to a match or competition, or otherwise improperly influence the outcome or any other aspect of a match or a competition.
Do not show unnecessary obvious dissension, displeasure or disapproval (by action or verbal abuse) towards an umpire or match official as a consequence of his or her decision or generally.
Abstain from the use of tobacco and the consumption of alcoholic beverages while in the playing/representative uniform.
Adhere to HA racial and sexual vilification policy.
Respect the rights, dignity and worth of every person regardless of their gender, ability, cultural background or religion.
Don’t do anything which adversely affects or reflects on or discredits the game of hockey, HA, any SA, or any squad, team, competition, tournament, sponsor, official supplier or licensee, including, but not limited to, any illegal act or any act of dishonesty or fraud.
Refrain from using obscene, offensive or insulting language and/or making obscene gestures which may insult other players, officials or spectators.

I have read and understood the Hockey Australia Player Code of Behaviour

Yes

I agree to abide by this code

Yes

Privacy

I understand that my/my child’s details will be kept confidential and that they will only be given to the team manager/coach, HAW and HAW insurance company if medical assistance is required.

Yes

Written permission must be gained if my/my child’s personal details are to be given to anyone other than the above mentioned.

Yes

Payments and Agreement

Payment of fees must accompany this registration. If you haven't paid your fees at this time, please follow the instructions HERE to pay your fees to both Hockey ACT and the Wangaratta Hockey Club immediately after you have completed this form. In the meantime, please let us know the status of your membership.

I have been informed of the Wangaratta Hockey Club registration fee, and I agree to pay it

(If you don't agree you cannot submit this form or play hockey with Wangaratta Hockey Club)

Yes

Wangaratta Hockey Club registration fee

I HAVE paid my Wangaratta Hockey Club registration fee

I have NOT paid my Wangaratta Hockey Club registration fee yet

Hockey ACT registration fee

I HAVE registered with Hockey ACT and paid my fees

I have NOT registered with Hockey ACT yet

I am aware there will be a fee for each match that I play, and I agree to pay it

Yes

Player/Guardian Name

Date Signed

Signed By

Player

Guardian

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*Please disclose any chronic or recurrent ailment, health condition, allergy or physical condition so that the correct information can be provided to health officials in case of an emergency. This information will only be shared with your coach, team manager and medical staff, if required.

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Membership Registration Form