(Office use only)
Staff name: __________________
Nomination Paid:  _
/ _ /16
SENIOR TEAM NOMINATION FORM
SEASON 2 – 2016, MULTIPURPOSE
Receipt # ___________________________________
By-laws Received 
Renominating 
Competition Nominating For (please tick)
Monday
 Men’s Basketball - PM
 Women’s Basketball - PM
Tuesday
 Mixed Volleyball (A Grade) - PM
 Mixed Volleyball (B Grade) - PM
Wednesday
 Mixed Futsal (A Grade) - PM
Thursday
 Mixed Netball (Outdoor) - PM
 Mixed Futsal (B Grade) - PM
Friday
Teams nominating into FUTSAL and BASKETBALL will be required to supply a referee.
Team Name / Contact Details
Team Name:
Team Captain / First Contact:
Address:
Telephone (M):
Telephone (W):
Email:
Alternative Team Contact
Team Vice Captain / Second Contact:
Address:
Telephone (M):
Telephone (W):
Email:
Game Fees (must be paid by both teams prior to games starting)
Non-Refundable Registration Fee = 1x game fee (covers prize-giving and administration costs)
Basketball
Volleyball:
$50.00
$60.00
Netball:
Futsal:
$70.00
$50.00
*Receive a 10% discount if you pay for the whole season upfront.
**Forfeited games still require payment please refer to the Stadiums By-Laws for more information.
***Bibs may be hired at no cost, however a deposit/keys will be required which will be returned to the team when the whole set is
returned to reception after the game in reasonable condition.
****Registrations will not be finalised unless ALL fields are completed.
Uniform (all players must wear the same coloured shirt as a minimum)
First Colour Preference:
Second Colour Preference (if first already taken by existing team):
Declaration
I warrant and declare that I have the authority to make this declaration and act accordingly on behalf of the team stated on this
form. I declare the team will participate in all scheduled matches for the duration of the season and honour any fines that are
imposed as a result of the team withdrawing or causing a match to be forfeited.
I declare that all players and spectators connected to this team will abide by the Centre’s bylaws and Codes of Conducts. I further
agree on behalf of the team, to fully indemnify the YMCA and Town of Port Hedland, and all employees of the YMCA and Town of
Port Hedland, against any claims arising which may be made against them. On behalf of this team, I understand that participation
in the Port Hedland Leisure programs are undertaken entirely at the team’s risk and no liability will be held against the YMCA or
Town of Port Hedland.
I understand that unforeseen circumstances may cause scheduled games to be altered or cancelled from time to time.
Signature of team captain:_____________________________________
Date:______________________
Player Information
Please provide the full details of each team member (no nick names, must include surname)
Name of Player
Email Address
Phone (M)
*If your team adds a new player during the season please update this form and hand it into Wanangkura Stadium reception.
Phone (W)