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Blacktown International Sportspark (BISP) Program – $110
Cricket NSW/AFL Entrance, Eastern Rd, Rooty Hill.
Monday 16th January and Tuesday 17th January, 2012
9am to 1 pm each day
What you receive• Sydney Thunder Shirt & Cap• Signed Sydney Thunder poster• Morning tea• Experienced coaches
at a state of the art facility
Appearances by Sydney Thunder and Lend Lease
Breakers PlayersAll equipment supplied by Cricket NSW
Enrolment FormName of Participant: M: F:
Address:
Phone: (H) (M) Age:
Email:
Emergency ContactIntheeventofanemergency,pleaseprovidethenameandphonenumberofthepersontocontact:
Name:
Relationship: Phone
PaymentPayment and registration can be made online at http://cnsw2012blacktown.eventbrite.com or please fill in and return this form.
Iencloseacheque/moneyorderfor$ payabletoCricketNSWOR
charge$ tocreditcard(Mastercard,Visa,Bankcard,AMEX):
Card No:
Card Type: Mastercard Visa Bankcard AmericanExpress
Expiry Date: /
Cardholder Name:
Cardholder Signature:
Doesyourchildhaveanyillnessorallergyforwhichmedicationisrequired? Yes No
Ifyes,pleasespecify:
Doesyourchildhaveaphysical,intellectualorsensorydisability? Yes No
Ifyes,pleasespecify:
Isthereanyotherinformationweshouldknowaboutyourchildrelatingtotheproposedactivity? Yes No
Ifyes,pleasespecify:
ConsentItheundersigned(formyself,myheirs,myexecutorsandadministrators)agreeonmybehalfandonthebehalfoftheParticipanttomychild’sattendanceandparticipationintheeventsoperatedbyoronbehalfofCricketNSW.
Privacy/Guardians ConsentIconfirmthatIamaparentorlegalguardianofthechild.Iacknowledgethatthereareinherentdangersassociatedwiththeprogramwhichmayresultinthechildbeinginjured.IagreebothonthebehalfofmychildandinmyownrighttoreleaseforeverdischargeCricketNSWfromanyandallliabilityforinjury,lossordamagehowevercausedarisingoutofthechild’sparticipationintheprogram.Iconsenttothechildreceivingtreatmentforanymedicalcondition,ifIamunabletobecontactedinanemergencysituation.Ialsoconsenttoanyimagesorvideofootageofthechildbeingusedforanyvideoreproductionormediaforthepublicityandpromotionofcricket.FurtherinformationonCricketNSW’sPrivacyPolicyisavailableatwww.cricketnsw.com
Signed by Parent or Guardian:
Print Name:
Date:
Please complete form (including overleaf) and RETURN FORM TO: Craig McLean – Cricket NSW Post: POBox23,Doonside,NSW,2767Ph: 0425237145Fax: (02)83026080Email:[email protected]
Limited spots available, registrations close Monday 9th January 2012.
For children
aged 7-12
years old
