New Page 3

WATER POLO QUEENSLAND INC

Application for Membership 2005/06

TAX INVOICE

85 300 761 576

All players, coaches, referees, volunteers and participants must sign the declaration below. Incomplete forms will not be accepted and will be returned.

Note – a Transfer Form must be completed if registering with a different club this year

CLUB*

PREVIOUS CLUB*

SURNAME*

GIVEN NAME*

STREET*

SUBURB*

STATE*

POSTCODE*

DATE OF BIRTH*

GENDER*

£ Male £ Female

HOME PHONE*

WORK*

MOBILE*

OCCUPATION/SCHOOL

EMAIL*

EMERGENCY CONTACT*

NAME*

REL’SHIP TO MEMBER*

ADDRESS

EMERGENCY PHONE*

EMAIL ADDRESS*

* Required Information

MEMBER CATEGORY Membership valid to 31^st August 2006 Fee inclusive of GST

NEW/RENEWAL

REGIONAL PLAYER NEW

OTHER

£ Senior

£ Non Playing

£ Junior

£ Winter Junior

£ School (School Competition only)

£ School (school competition only)

£ Winter Senior

£ Flippa

£ Affiliate/Associate

I wish to receive email circulars

I wish to be contacted about referee accreditation

I wish to be contacted about coaching accreditation

£ YES

£ NO

Please indicate if you are prepared to allow the Association to provide your address details to Association sponsors. Your approval to pass this information on would be greatly appreciated. £ YES £ NO

Information on this form is entered into Water Polo Queensland’s (QWPI) and Australian Water Polo Inc’s (AWPI) database of registered members or officials. Database information may be passed onto relevant affiliated State bodies from time to time. Coaches or officials may be sent relevant information as a consequence of a member’s inclusion in a representative team. Information will be disclosed in accordance with the Association’s Privacy Policy which can be viewed via the AWPI web site www.waterpoloaus.asn.au

DECLARATION

1. I hereby apply for membership of QWPI and to agree to abide by the provisions of the Constitution and By-Laws of QWPI and AWPI. I will also abide by all QWPI policies and AWPI policies applicable to my membership including Anti-Doping Policy, Codes of Behaviour and Member Protection Policies which can be viewed via the AWPI web site www.waterpoloaus.asn.au. Or QWPI website www.waterpoloqld.com.au

2. I tender the appropriate fees necessary for the consideration and acceptance of my Application for Membership.

3. I acknowledge that the sport of water polo involves strenuous exercise and physical contact. I accept any risk my involvement may have.

4. I understand and agree that any photographs, film or images of me or any other media information in connection with me or my activities with AWPI or any of its affiliates are and remain the property of AWPI and may be used by AWPI for any form of publicity or advertising which AWPI in its sole discretion desires to use.

5. I hereby represent the information given in this application is true and correct to my knowledge.

Signature of Applicant

Date

Parent/Guardian to sign if Player under 18 years of age

Signature of Parent/ Guardian

Date

Please turn over.........

OFFICE USE ONLY

REGISTRATION NUMBER:

DATE RECEIVED:

AMOUNT PAID:

RECEIPT NUMBER:

I, ................................................................................................ the player named below, ACKNOWLEDGE:

· The activities associated with training for and playing water polo can be hazardous and that serious accidents causing death, bodily injury, disability and damage (including property damage) can and do happen;

· Water Polo Queensland Inc (“QWPI”) through its affiliation with Australian Water Polo Inc maintains limited insurance cover on players registered with QWPI provided such registration is current at the time of the event giving rise to a claim on such insurance (“the Insurance Scheme”).

IN CONSIDERATION of my being allowed to participate in the sport of water polo administered by QWPI and/or in consideration of the benefits which are available to me (or on my behalf) through the Insurance Scheme (the Schedule of Benefits of which I have read, acknowledged and accepted as being reasonable compensation, available on AWPI Web site www.waterpoloaus.asn.au)

· Acknowledge and assume all risk of death, bodily injury, disability or damage (including property damage);

· Waive all claims which may be made by me or on my behalf against AWPI, QWPI, its servants, agents and all persons and corporations operating under its auspices and authority and all players, referees, coaches, trainers and others registered with it (individually and collectively called “Associates”) for death, bodily injury, disability or damage (including property damage);

arising by, through or in connection with QWPI caused or contributed to by acts of negligence or breach of contract by QWPI and its Associates to the full extent permitted by law.

FURTHER FOR THE CONSIDERATION set out above I indemnify QWPI and its Associates against all liability arising as a result of my negligence (or the negligence of my servants or agents) in respect of any death, bodily injury, disability, damage (including property damage) occurring as a result of such negligence to the fullest extent permitted by law but only to the extent that QWPI and its Associates are not already indemnified or insured.

I AM AWARE this is a legal document and that I have had the opportunity of taking independent legal advice on it. After taking such advice (or waiving my right to do so) I confirm that I have signed this Agreement of my own free will knowing that I have relinquished important legal rights.

In the case of the above named player being under the age of eighteen (18) years, I, the parent or guardian of such player acknowledges I have read this document and have had the opportunity of taking independent legal advice on it. After taking such advice (or waiving my right to do so) I confirm I have accepted its terms on behalf of such player and in consideration of such player being allowed to participate in the sport of water polo administered by QWPI I indemnify QWPI and its Associates against all liability arising as a result of such player’s negligence (or the negligence of such player’s servants or agents) in respect of any death, bodily injury, disability, damage (including property damage) occurring as a result of such negligence to the fullest extent permitted by law but only to the extent that QWPI and its Associates are not already indemnified or insured.

Name: ……………………………………………………………………

Phone:Home - ………………………………Mobile:…………………………………………………………

Email:…………………………………………………………………………………………………………….

Club Fees- Full fee payment is required by Friday 7 October 2005 or player unable to legally enter the water.

Skills Enhancement Program – optional Wednesday evenings 5.30 – 7 and/or Sunday afternoon 4 – 5.30 ($32 for 1 session or $50 for both sessions)starts 28^thSeptember

First game for juniors – Saturday 8^th October for 8 weeks, recommences in 2006.

Information on draws and BWPI rules will be emailed to you as soon as available.

ACLC “Swim for Polo” Wednesday & Friday 6.30-7.30 Cost $8 per visit or 30 visit pass for $70.

Please tick where you prefer to assist. Time is precious, so are the children*

(Some positions will be on a roster basis for all families)
. Team Manager p . Game Set Up* p . Coach p

U13 (1993)	p	A-Grade	p	U13 (1993)	p	A-Grade	p
U14 (1992)	p	B-Grade	p	U14 (1992)	p	B-Grade	p
U16 (1990)	p	X-Grade	p	U15 (1991)	p	X-Grade	p
U18 (1988)	p			U16 (1990)	p
				U18 (1988)	p