Senior Representative Player Form Agreement Covering Player and Player’s Parent/s (or Guardian) This agreement and subsequent form (Senior Representative Player Details) must be signed by the player and parent/guardian (if under 18 years) where indicated and submitted (followed by payment of deposit) as soon as possible, to be eligible for the season Participation and involvement in the Association’s Senior Representative Program by both the Player and Parent/s or Guardian (if applicable), is conditional upon acceptance of the terms and conditions included in the Senior Representative Manual, Guidelines & Policies Agreement. Senior Representative Player DetailsPlayer Name* Gender* Mens Womens Date of Birth* DD slash MM slash YYYY Email* Phone*Address* Street Address City State Post Code Occupation* Place of Employment* Parent / Guardian Details (if player is under 18 years)RelationshipMotherFatherGuardianName MobileHome Phone Work Phone Email Parent / Guardian DetailsRelationshipMotherFatherGuardianName MobileHome Phone Work Phone Email Special CircumstancesPlease advise if there are any special circumstances (ie, court orders, custody matters) of which the Senior Representative Management Committee, Team Coach, Manager or the Board of Management of the Tamworth Basketball Association should be made aware. Medicare Number* Ambulance Cover* Yes No Private Health Cover* Yes No If Yes, provide health fund name & membership number Details of any medical conditions / allergiesMedication should be clearly marked and the Team Manager made aware of any changes and action to be taken in case of an emergency). Appropriate medical / hospital treatment will be sought as a result of any accident or injury. Medication*I give permission to be given the recommended dose of paracetamol and or prescribed medication if deemed necessary due to pain, injury, or allergic reaction. Prescribed medication requires detailed instruction on how to apply or use and a copy to be given to Manager and Administrator for records. I give permission I DO NOT give permission Signed by Player (or Parent / Guardian if under 18 years)Signature*Date* DD slash MM slash YYYY Sponsorship Affiliation One of our sponsors, Wests Entertainment Group, provides a program for sporting groups, players and families to affiliate their membership so that our association makes a stronger partnership between our joint members. Every dollar you spend on dining at a Wests venue, will then be recognised and can assist in the return of our sponsorship. For more information click here If you would like to link your Wests membership to the Tamworth Basketball Association please fill in your Wests member number/s below otherwise leave blank and just click Submit. Name Wests Membership Number Name Wests Membership Number HiddenOld Field - Maintain for Data: Player Name HiddenOld Field - Maintain for Data: Parent / Guardian Name (if player is under 18 years) HiddenOld Field - Maintain for Data: Player SignatureHiddenOld Field - Maintain for Data: Parent SignatureHiddenOld Field - Maintain for Data: Date DD slash MM slash YYYY
