VALLEYS HOCKEY CLUB
JUNIOR REGISTRATION
FORM
2014
www.valleyshockey.com.au
Surname: __________________________________________________________________________ ___
First Name: ________________________________ Middle Name: _______________________________
Gender:
Male 
Female 
Date of Birth: ______________________________
Address: ______________________________________________________________________________
Suburb: ___________________________________ State: _________ Post Code:__________
Phone: (H) _______________________________________ (M)_________________________________
Email: ________________________________________________________________________________
Registration Type: for above named player registering in any of the following Competitions, tick relevant box:
Girls

Boys

Junior Player also wishes to play in a senior grade? (Circle)
Minkey 
No
Yes: in grade________________
Your School or College
Parent or
Guardian
First
name
Family
name
Phone
Email
Relation
-ship to
player
NOTE: Only the parent/guardian listed above will be given club member voting rights and free membership of our sponsor, The
Burns Club (please complete the separate Burns Club nomination form)
Secondary
First
Family
Relation
Contact
name
name
-ship to
player
Phone
Email
NEW MEMBERS ONLY
Name of Club last played with:
City/ Town:
Year:
Umpiring Skills: Have you attended an Umpiring Seminar (circle)
No
Yes
What year?
Privacy Statement
Valleys Hockey Club Incorporated is committed to the protection of your personal information. Any personal information provided by you to Valleys
Hockey Club Incorporated will be used for administrative, statistical and related purposes which can be reasonably expected. Personal information
will also be provided to Hockey ACT and may be used for communicating marketing or commercial information.
Tick this box if you do not wish your personal information to be used by Hockey ACT for communicating commercial information

Hockey ACT will not disclose any personally identifiable information obtained from you or Valleys Hockey Club, on your behalf, to other parties or for
purposes other than stated above.
Information provided by various means will be kept safe and secure by Hockey ACT and Valleys Hockey Club. At anytime, you may advise if you no
longer wish to receive marketing materials or other commercial communications from Hockey ACT. This request must be made in writing to Hockey
ACT.
JUNIOR PLAYER CONTRACT
I _________________________________________________ (“the player”) wish to play for Valleys Hockey Club (“the Club”) in Hockey
ACT’s Winter Hockey Competition in 2013. I agree that if I do not abide by the Players Guidelines and Code of Conduct adopted by the
Club for players that, from time to time I may be excluded from playing even though my fees have been paid. I agree to comply with the
rules, regulations and by-laws of Hockey ACT.
Signed: _______________________________________________________ (Player)
I am the player’s parent/guardian.
I give permission for my daughter/son to attend hockey practice and to play in matches in the 2014 season. I acknowledge that I am
responsible for ensuring adequate supervision and protection from injury of him/her during practice and during the course of play. I
acknowledge that I will be responsible for all dental, medical, ambulance and hospital expenses not covered by Hockey ACT insurance
resulting from any injury sustained by my child during practice or the course of play, and for making and administering any claims to the
insurer. I authorise an officer or agent of the Valleys Hockey Club to obtain such medical assistance or treatment he/she deems
necessary.
I understand that the Club will nominate a team in the competition on her/his behalf and as a result must make payments to Hockey ACT
throughout the season, and will also incur expense including provision of playing uniforms, equipment, facilities and in administration.
I acknowledge that the Club depends on payments by players to meet these expenses and agree to pay fees in instalments as set out
below. I agree to engage in such fundraising activities throughout 2014 as the Club Committee may determine.
I agree that if I do not pay an instalment when it is due (as shown below)

The whole of the unpaid fees for the season will then immediately become due, and the Club may
immediately take action to recover those fees as a debt due to the Club

The player will not be eligible for selection to play until the instalment is paid, nor will she/he be given a
clearance to play for another club.
I understand that the player will be covered by the Sports Personal Accident Insurance Policy as arranged by Hockey ACT through
Sportscover Australia P/L t/a Sportscover. Policy details are available from Hockey ACT.
Signed: ________________________________________________________ Date:_______/_______/_2014
FEES - paid in FULL by the end of Round 1 will attract a $10.00 discount. Family discount is available for 3 or
more members of an immediate family. Please ask your team manager for details.
MINKEY FEES
$85 per player
JUNIOR FEES
U13s - U18s
$280
Boys & Girls
JUNIOR also playing
SENIORS
U11s
$190
Club junior pays one fee i.e. the Club senior fee (see senior form for rates)
PAYMENT SCHEDULE
JUNIOR &
MINKEY
Deposit
Due on Registration
50% of fees
2nd Instalment
Due 10/11 May 2014
Balance of fees payable
PAYMENT
Payment may be made by the following methods:
DIRECT DEBIT PAYMENT to VALLEYS HOCKEY CLUB BANK ACCOUNT

Direct deposit to Valleys Barton Hockey Club BSB 112 908 Account 050768042. Please ensure you
specify who the payment is from (eg Jones SL1 rego), and then email the deposit receipt to the club
treasurer [email protected] (preferred option)

Cash, cheque or credit on registration day