Membership Registration Form

I am registering my interest in playing for the following team/s:
Gender
Ambulance Cover
Private Health insurance
Is medication and/or a treatment plan required for the above condition?
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Medical Consent – 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.
I/my guardian, will take responsibility for all necessary emergency medical costs, including ambulance.
Image Capture and Use – I give permission for myself/my child to be photographed while at hockey clinics, games, activities, fundraising events and training sessions.
In addition, 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.
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.
I have received, read and understood the Hockey Victoria Code of Behaviour. *
I agree to abide by this Code. *
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.
Written permission must be gained if my/my child’s personal details are to be given to anyone other than the above mentioned.
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. *
I have been informed of the Wangaratta Hockey Club registration and I agree to pay it.
I have been informed of the Hockey Victoria registration, and I agree to pay it.
I am aware there will be a fee for each match that I play, and I agree to pay it.
Signed By
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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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