Queenscliff

Football and Netball Club Inc.

2015 Membership Application Form

Member Applicant Details

For family membership, one parent/guardian must complete this section to begin
family registration. (Please print clearly)
Title
Surname
Christian Name
Mr Mrs Ms

Address

Postcode
Date of Birth
Gender


Male Female
Mobile Number
Home phone (if applicable)


Email address
Other Emergency Contact Number
Membership Options Please tick one option only
Senior Football
$250
Family Membership
$280
Senior Netball
$180
Junior: Football $110 Netball $90
Senior Football Concession $180
Adult Non Playing
$60
Senior Netball Concession
$130
Adult concession/senior
$40
Payment:
Cheque Cash Mastercard Visa Card #:
If you played for another club in the past 2 years please write the name of that club below:

Netball Membership excludes VNA.
Please note that the club recommends that all players have Ambulance cover and Private
Health Insurance.
The following section is for family membership information only.
Junior player registration details
Surname
Christian Name
Gender
Date of Birth
Age Group

























Non playing family members
Surname
Christian Name

VNA number
Paid at
Receipt number
QFNC Membership ID numbers (office use only)

Please note that your membership of the Queenscliff Football and Netball Club gives
automatic membership of the Queenscliff Sports Club

*Please read, and complete the declaration on the reverse side of this form


Important Information Please read and agree to the following
Consent
I understand that the Queenscliff Football and Netball Club Inc. will participate in affiliated
football and netball competitions, and other football and netball competitions from time to
time.
I understand that the information I have provided is necessary for the function of the club. I
acknowledge and agree that the information will be disclosed to Football and Netball Geelong,
BFL, BFL-Netball, VCFL or Netball Victoria for the purposes of registration.
I have read the codes of conduct for players and spectators and agree to abide them*.
I understand that there is a risk of injury in playing football or netball. I authorise any official
from the Queenscliff Football and Netball Club Inc. in charge of my team, in the event of injury
or illness, to obtain on my behalf, and at my expense, any medical assistance, treatment and
transportation as deemed necessary.
* The QFNC Code of Conduct is included in the Members Handbook which is available on request by emailing
admin@qfnc.com.au

Indemnity
Except where provided or required by law and such cannot be excluded, I agree that the
Queenscliff Football and Netball Club Inc. and its respective directors, officers, members,
servants or agents are absolved from all liability however arising from injury to me, however
caused, arising whilst participating for the Queenscliff Football and Netball Club Inc.

Photo Use
The Queenscliff Football and Netball Club may respectfully use my photos from club events in
electronic and paper media.



I have read, understood and agree to the above terms.
I warrant that all the information provided is true and correct.

Signed: Player (or parent guardian if under 18)


__________________________________________________________________________ Date: ___________________


Name: (Please print)






Thank you for joining the great Queenscliff Football and Netball Club!
Have a great 2015 playing for, and/or supporting our club.