BLIND CRICKET NSW - APPLICATION FOR MEMBERSHIP - 2011/2012

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

Date of Birth
	
Email	

Phone:	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	

Emergency Contact: 
	Name
	Phone

Medical Information:
Please detail any medication you are taking:


Please detail any allergies you have:


Please detail any medical conditions we should be aware of in an EMERGENCY:


I agree that the information I have provided is correct, I agree to be bound by BCNSWÕs rules, conditions of membership and code of conduct while on BCNSW grounds or at BCNSW sponsored functions, and I acknowledge that my information, including medical details and email address will be stored, accessible and updatable, in accordance with BCNSWÕs privacy policy.  
I will notify the BCNSW Secretary if any of my details change

Signature
	
Date	



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