Multisport Nomination

Multisport Nomination Form
Team Name: *
Team Captains Name *

First Name Last Name
Team Captain's Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Team Captain's Phone Number: *
Team Captain's Email: *
Secondary Contacts Name *

First Name Last Name
Secondary Contact's Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Secondary Contact's Phone Number: *
Secondary's Email: *
Sport: *
Grade: (request only) *

A B C
Please note: If there are not enough teams to generate a grade, teams will be combined within the nearest grade available on that night and the grade may or may not split for finals.
Fixturing Consideration: (please specify any considerations you wish LLC to try and take into account when processing your nomination)
These considerations are requests only and are not to be considered guaranteed. While attempts to accommodate requests will be made when possible, the priority of LLC is to ensure as fair a draw for all teams as possible. All teams should expect to play a fair spread of all game time slots, and if you can not field a team for a fixtured match you will be required to forfeit the game (with fees applying – see conditions of registering a Team)
Team Shirt Colour: *
Team Bottoms Colour: *
Team Bib Colour: *
Player Registration:

Minimum of 5 players required.
Number of Players to be Registered:
PLAYER 1
Name *

First Name Last Name
DOB: *

Day Month Year
Date
Phone: *
PLAYER 2
Name *

First Name Last Name
DOB: *

Day Month Year
Date
Phone: *
PLAYER 3
Name *

First Name Last Name
DOB: *

Day Month Year
Date
Phone: *
PLAYER 4
Name *

First Name Last Name
DOB: *

Day Month Year
Date
Phone: *
PLAYER 5
Name *

First Name Last Name
DOB:

Day Month Year
Date
Phone:
PLAYER 6
Name *

First Name Last Name
DOB:

Day Month Year
Date
Phone:
PLAYER 7
Name *

First Name Last Name
DOB:

Day Month Year
Date
Phone:
PLAYER 8
Name *

First Name Last Name
DOB:

Day Month Year
Date
Phone:
PLAYER 9
Name *

First Name Last Name
DOB:

Day Month Year
Date
Phone:
PLAYER 10
Name *

First Name Last Name
DOB:

Day Month Year
Date
Phone:
Played in an LLC Comp previously? *

No Yes (provide previous team name)
Previous Team Name:
How did you hear about our competition?

Word of Mouth Radio Newspaper
Is there another competition you'd like to see run at LLC?
Declaration - the declaration must be signed and dated for this nomination to be accepted. By ticking the box below, I agree to the following:

1. To abide by the rules of Leschenault Leisure Centre.

2. That I have read and understood the Conditions of Registering a Team and the Bylaws

3. The Shire of Harvey will not be responsible for any injury suffered by either participant or non-participant members of the group while using facilities: whether the injury be self inflicted, caused by another member of the group, or caused by another person not associated with the group.The Shire of Harvey will not be liable in any way for any loss of, or damage to the property of members of the group, whether members or non-members of the group cause the loss or damage.The above does not apply to the extent that any injury, loss or damage is caused or contributed to by the willful negligent or other unlawful act of omission of the Shire of Harvey or any of its employees, officers, agents or contractors.

4. I warrant and declare that I have, on behalf of all team members named on this form the authority to make this declaration. I declare that we will participate in all matches programmed for the duration of the season (including finals matches) and undertake to honour fines that may be imposed as a result of this team causing a match to be forfeited and any fees associated with the collection of fees oweI further again, being authorised by the team and on behalf of all members of the team, agree to at all times, fully indemnify the owners, agents and employees of the Leschenault Leisure Centre against any and all claims, however arising, which may be made against them as a result of our team’s use or participation in or presence within the Leschenault Leisure Centre.
Declaration:

I have read and agree to the declaration above
Enter text: *
ADMIN USE ONLY
Received on:
Staff Name:
Nomination Fee Paid:

Yes No
Receipt Number:
Should be Empty:

Multisport Nomination Form