Mixed Volleyball Fellowship Games - Westminster Presbyterian Church Bull Creek

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Westminster Presbyterian Church Bull Creek

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Mixed Volleyball Fellowship Games

Queries: wpcbc.sportsministry@gmail.com

Sat 19 Nov 2022 11.30am - 5.00pm LeisureFit Melville, 431 Canning Highway, Melville. Cost $10pp - payable by cash on the day. This event is run by the WPC Bull Creek Sports Ministry. Please complete a form for each person attending.

I am/the person I am registering is *

Under 18
Over 18

My team is

Surname *

Given Name *

Gender *

Male
Female

Date of Birth *

Phone Number *

Email *

Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Emergency Medical Details

Medicare Card Number *

Medicare position number e.g 1,2,3

Do you/the person you are registering have a Private Health Fund? *

Yes
No

Allergies

Do you/the person you are registering have any allergies? *

Yes
No

Does you/the person you are registering have any medical conditions? *

Yes
No

Emergency Contact Information

Contact person in case of emergency *

Relationship to you *

Emergency contact number *

Consents

In attending Mixed Volleyball Fellowship Games, I undertake the following

I consent that WPC Bull Creek Sports Ministry may use photos and/or video footage of me/my child for website/newsletter/other publication purposes *

Yes
No

I authorise the WPC Bull Creek Sports Ministry leaders, committee and volunteers, where it is impractical to communicate with me, to arrange for medical treatment for me/my child as deemed necessary by a qualified medical practitioner *

Yes

I authorise the use of ambulance for me/my child should it be deemed necessary and authorise the use of anesthetics by a qualified medical practitioner if in his/her judgment it is deemed necesary *

Yes

Indemnity

In attending/my child attending the Mixed Volleyball Fellowship Games, I undertake the following:

I, the undersigned agree that in the event of requiring medical attention, I acknowledge that any costs incurred will be my responsibility and I agree to reimburse WPC Bull Creek and its employees, committee members and/or volunteers for all costs which they incur on my/my child's behalf.

I agree that I will/my child will abide by the rules, guidelines and instructions given at the Mixed Volleyball Fellowship Games by its employees, committee members, volunteers, and WPC Bull Creek pastors, elders, deacons in charge, in respect of the activity.

I accept all reasonably forseeable risks associated with the Mixed Volleyball Fellowship Games program and activities for me/my child. I acknowledge that this acceptance is a condition precedent to me/my child taking part in any capacity in the Mixed Volleyball Fellowship Games.

I hereby release, hold harmless and forever discharge the Mixed Volleyball Fellowship Games leaders, committee members, volunteers, and WPC Bull Creek church leaders against any claim whatsoever arising out of or related to any forseeable loss, property damage or personal injury that may be sustained by me/my child or to any property belonging to me/my child while in attendance of the duration of the program.

I agree that this document may be pleaded in bar to any claim arising from risks normally associated with the activity, made by me/my child or on behalf of me/my child or my/my child's executors, administrators or other personal representatives arising out or in respect of the WPC Bull Creek church and its Sports Ministry and Mixed Volleyball Fellowship Games.

The indemnity and release contained in this document will be enforceable against me/my child and my executors, administrators and other personal representatives.

I certify that this information is true and correct to the best of my knowledge and that it will be valid for the Mixed Volleyball Fellowship Games. I understand that failure to disclose changed or new information to the organisers, committee members, leaders or volunteers of Mixed Volleyball Fellowship Games, will be at my own risk and in no way be the responsibility or fault of WPC Bull Creek Sports Ministry or WPC Bull Creek if information is not disclosed.

Signature *

Date *

Name