Derinya Basketball Club
ABN: 28 737 465 812
President: Narelle Davis
Enrolment Officers:
Leanne Duffey & Bill Knott
www.derinyabasketball.com.au
JUNIOR REGISTRATION FORM
PLAYERS FIRST NAME: ______________________________ SURNAME: ___________________________________
ADDRESS: _______________________________________________________________________________________
DATE OF BIRTH:
________________________ GENDER: male / female
(please circle)
YEAR AT SCHOOL:___________ TEACHER: __________________________________________________________
Have you played for Derinya before:
YES / NO
If yes, what is your player Number:__________
Are you a representative player (eg. Blues / Breakers) YES / NO If yes, what team do you play for: _______________
ADDITIONAL INFORMATION
Mothers Name: ___________________________ Phone (H) ____________________ (Mob) ______________________
Fathers Name: ___________________________ Phone (H) ____________________ (Mob) ______________________
Email Address: ____________________________________________________________________________________
Are there any medical conditions that we need to be aware of? (eg. Asthma)____________________________________ (PLEASE advise
your child’s coach and team manager of any medical conditions upon starting the season)
I, _________________________________ being the parent, legal guardian and / or authorising person of the child named above do hereby:

give permission for the Derinya Basketball Club Inc. to use my child’s first name (only) and photo on the clubs website or
newsletter for the purpose of acknowledgement, club advertising and commendation only; YES / NO

give permission for the child named above to play basketball in a Basketball Competition conducted by the Frankston & District
Basketball Association and agree to abide by any code of conduct applicable to me and spectators associated with me, when
attending my child’s game(s) in whatever capacity I act (i.e. parent, coach, team manager, etc) as required by the Victorian
Basketball Association and adopted by the FDBA or any other association and Derinya Basketball Club Inc; and

agree to become a member of the Derinya Basketball Club Inc and be bound by the constitution, rules, by-laws, regulations, policies
or any other such guidelines applicable to the Derinya Basketball Club Inc. and its members.
Signed: _____________________________________ Date: __________________
FOR EFT PAYMENTS
CLUB USE ONLY
Account Name: Derinya Basketball Club
BSB:
633-000
Account Number: 149781064
In the reference field please include your child’s name
Receipt Date: ______________ Receipt No. __________
Cash / Cheque (circle)
EFT Receipt Number: ______________________
PARENT ASSISTANCE AND SUPPORT
If you could assist with any of the below positions, please circle. Prior experience isn’t required. Thank you.
Coach
Assistant Coach
Team Manager
Committee
Occasional helper
For any enquiries, please contact the enrolment officer: Bill Knott
0408 180 322 (U8 to U10) or
Leanne Duffey 0422 276 362 (U12 to U18)