BLIND CRICKET NSW - APPLICATION FOR MEMBERSHIP – 2011/2012

Membership fees are due on or before 20th August, 2011

Player - Adults - $70.00 includes membership, match fees & insurance
Player - Juniors under the age of 16 - $35.00 includes membership, match fees & insurance
Non Player - Adults - $35.00 includes membership & insurance

Name
	
Address
	
Email	

Contact Numbers	
	work
	home
	mobile


Eye Classification
(Fully, B1, B2 or B3)		
If fully sighted, in what capacity are you involved ?

Rail Pass Number and Pension Number or N/A	

Signature
	




Date	



Blind Cricket NSW use only
--------------------------
Membership fees paid	
Membership approved	
Membership number	
Eye test completed	
Development Cricketer