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Choose your clinic:		Dribble and Shoot (Ages 6-12)
Player's First Name:
Player's Surname:
Player's Gender:		Girl Boy
Player's Date of birth:
Player's current age and age group is: (calculated)

Home Address:
Suburb:
Postcode:
Home Phone: (no spaces)
Player's or Contact Mobile Phone: (no spaces)

Basketball Experience		Never Played School PE Only Netball Only 1-2 Seasons 3-5 Seasons 5 or More Seasons

Responsible Parent or Guardian's Name:
Responsible Parent or Guardian's Mobile:
Contact Email Address:

Emergency Contact Name:
Relationship to Player:
Emergency Contact Number:
Does your child have any of the following medical conditions? Asthma Diabetes Epilepsy ADHD Allergies - please specify:
Any other medical conditions we need to know about:
Medical Consent:
I consent to the treatments ticked below:
1. administer basic first aid treatment to my/our child in the event of illness or injury during the course of any training session, basketball game or other activity associated with the Club (including travelling to or from such activity); 2. call an ambulance in the event of illness or injury if necessary to do so during the course of any training session, basketball game, or other activity associated with the Club; 3. permit my/our child to be given a general anaesthetic and to be operated on in the case of a medical emergency if such treatment is considered necessary by a duly qualified medical practitioner during any period my/our child may be participating in any activity associated with the Club (such permission being given on the proviso that every effort will be made to contact me/us personally before any decision is taken to anaesthetise and operate).

PHOTO APPROVAL I allow all photographs taken of my family at Atoms Holiday Camp to be used for promotional materials. While I agree to this, I understand that all promotional material that uses this photography will be tasteful, professional and will no way cause stress to my child or family. I understand that I can expect no payment for this photography. YES or NO (PLEASE SELECT NO IF YOU DO NOT WISH YOUR CHILD TO BE IN PROMOTIONAL PHOTOGRAPHS)

INDEMNITY CLAUSE By submitting this form, I, the responsible parent or guardian named above, approve of the enrolment and agree to abide by the rules and conditions of the Atoms Holiday Camp. I authorize you in the event of a unforeseen accident or illness to obtain such medical assistance as necessary and agree to meet any expense hereto as above. I also accept full responsibility of my child's belongings whilst attending this program.

Comments or questions:

The above information is provided in confidence to assist the relevant coach or committee members of the Club and will not be disclosed to any person other than a medical practitioner or paramedic who is consulted to treat your child. In relation to steps taken in accordance with the above authority, I/we, on my/our own behalf and on behalf of my/our child, agree not to make any claim or bring any legal claim against the Club, its committee, coaches, team managers and other parents or persons who are requested to assist in acting in accordance with the above authority. By clicking the REGISTER button, you agree that all information provided on this form regarding my/our child is true and accurate.
After you click REGISTER below, you will be provided with a link to TryBooking to pay for your child. Your registration is not complete and your child's place is not secure unless payment is made in full. Please note if you wish to register multiple children for this event you must fill out this form for each child, however you may make a single payment to cover all registrations.

Atoms is a member of the Camberwell Dragons Basketball Association, based in Melbourne, Victoria, Australia

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