Gauteng Water Polo Association's Bank Account:
Bank: Standard Bank
Account Number: 000199044
Branch Number: 000205 or 00020500
Your Reference: Initials, Surname, Age and Gender
Example: RM Smith U19 G
(Note: Please add an additional R10 for cash deposits)
Players Medical and General Indemnity Form
MEDICAL & GENERAL INDEMNITY FORM
PLEASE NOTE THAT NO CHILD MAY PARTICIPATE IN ANY GSWP OR SA SCHOOLS EVENT UNLESS THE INDEMNITY FORM IS COMPLETED AND SIGNED.
I, __________________________________
[Full name and surname of parent/guardian],
the legal parent / guardian of
_________________________________________________________________
[Full name and surname of player / participant]
Participants Age:________
Participants School: ________________________
Cell: _______________________________ hereby give permission for him/her to participate in the sporting activities of Central Gauteng Schools Water Polo and SA Schools Water Polo ("the Club"), and to go on approved Club tours and excursions related to such sporting activities.
I hereby indemnify and hold the Club, its agents, representatives, coaches and managers harmless against any claim or demand arising from the death of, or injury to, my child or any loss of or damage to property, person or funds, of whatsoever nature and howsoever sustained, including consequential loss, arising from or occasioned by my child's participation, in any such sporting activities and/or such tours and excursions.
I agree that, if in the opinion of the Chairperson of the Club or his delegated deputy, an emergency has arisen and medical treatment be deemed necessary for my child, the Chairperson of the Club or his delegated deputy shall have the authority (which is hereby delegated to the extent such delegation may be required) to consent to such medical treatment, including surgical intervention, on my behalf.
I accept that reasonable precautions will be taken to ensure the safety and welfare of my child and that I will be held responsible for the payment of medical, hospital or other accounts which has accrued applicable to my child.
I accept that I will be held accountable and liable for any actions by me, my child or my proxy that is reasonably deemed so by the Chairperson of the club or his delegated deputy.
As far as I am aware my child is physically and psychologically capable of participating in the said sporting activity and he/she is in good health. However, the persons responsible should please note the following: [Please state aspects that the staff should be aware of, e.g. allergies, tendency towards abnormal bleeding, epilepsy, diabetes, recent injury, relevant surgery, routine medication, etc.]
PLEASE NOTE: _______________________________________________________
The following information is essential in case of medical treatment or hospitalisation:
PARENT TO CONTACT: Name___________________________________
Cell: ___________________________________
tel. W
tel. H
PARENTS EMPLOYER:
Name: _________________________
address: _________________________________
tel.
MEDICAL AID FUND:
Name: _________________________
Membership No: ___________________________
tel.
FAMILY DOCTOR:
Name: _________________________
tel. W
tel. H ________________________________
SIGNATURE OF PARENT/GUARDIAN:___________________________________
DATE:_________________ I.D. NUMBER:_______________________
SIGNATURE OF WITNESS:____________________________________________
DATE:_________________ I.D. NUMBER:_______________________ _______________________________ PLACE
PLEASE NOTE THAT NO CHILD MAY PARTICIPATE IN ANY GSWP OR SA SCHOOLS EVENT UNLESS THE INDEMNITY FORM IS COMPLETED AND SIGNED.
I, __________________________________
[Full name and surname of parent/guardian],
the legal parent / guardian of
_________________________________________________________________
[Full name and surname of player / participant]
Participants Age:________
Participants School: ________________________
Cell: _______________________________ hereby give permission for him/her to participate in the sporting activities of Central Gauteng Schools Water Polo and SA Schools Water Polo ("the Club"), and to go on approved Club tours and excursions related to such sporting activities.
I hereby indemnify and hold the Club, its agents, representatives, coaches and managers harmless against any claim or demand arising from the death of, or injury to, my child or any loss of or damage to property, person or funds, of whatsoever nature and howsoever sustained, including consequential loss, arising from or occasioned by my child's participation, in any such sporting activities and/or such tours and excursions.
I agree that, if in the opinion of the Chairperson of the Club or his delegated deputy, an emergency has arisen and medical treatment be deemed necessary for my child, the Chairperson of the Club or his delegated deputy shall have the authority (which is hereby delegated to the extent such delegation may be required) to consent to such medical treatment, including surgical intervention, on my behalf.
I accept that reasonable precautions will be taken to ensure the safety and welfare of my child and that I will be held responsible for the payment of medical, hospital or other accounts which has accrued applicable to my child.
I accept that I will be held accountable and liable for any actions by me, my child or my proxy that is reasonably deemed so by the Chairperson of the club or his delegated deputy.
As far as I am aware my child is physically and psychologically capable of participating in the said sporting activity and he/she is in good health. However, the persons responsible should please note the following: [Please state aspects that the staff should be aware of, e.g. allergies, tendency towards abnormal bleeding, epilepsy, diabetes, recent injury, relevant surgery, routine medication, etc.]
PLEASE NOTE: _______________________________________________________
The following information is essential in case of medical treatment or hospitalisation:
PARENT TO CONTACT: Name___________________________________
Cell: ___________________________________
tel. W
tel. H
PARENTS EMPLOYER:
Name: _________________________
address: _________________________________
tel.
MEDICAL AID FUND:
Name: _________________________
Membership No: ___________________________
tel.
FAMILY DOCTOR:
Name: _________________________
tel. W
tel. H ________________________________
SIGNATURE OF PARENT/GUARDIAN:___________________________________
DATE:_________________ I.D. NUMBER:_______________________
SIGNATURE OF WITNESS:____________________________________________
DATE:_________________ I.D. NUMBER:_______________________ _______________________________ PLACE
Adult Indemnity Form
PLEASE NOTE THAT NO PERSON MAY PARTICIPATE IN ANY CGSWP OR SA SCHOOLS EVENT UNLESS THE INDEMNITY FORM IS COMPLETED AND SIGNED.
I,___________ __________________________________ [Full name and surname], being of legal age, hereby give consent to participate in the sporting activities of Central Gauteng Schools Water Polo and SA Schools Water Polo ("the Club"), and to go on approved Club tours and excursions related to such sporting activities.
I hereby indemnify and hold the Club, its agents, representatives, coaches and managers harmless against any claim or demand arising from the death of, or injury to, myself or any loss of or damage to property, financial status, of whatsoever nature and howsoever sustained, including consequential loss, arising from or occasioned by my participation, in any such sporting activities and/or such tours and excursions.
I agree that, if in the opinion of the Chairperson of the Club or his delegated deputy, an emergency has arisen and medical treatment be deemed necessary for myself, the Chairperson of the Club or his delegated deputy shall have the authority (which is hereby delegated to the extent such delegation may be required) to consent to such medical treatment, including surgical intervention, on my behalf.
I accept that reasonable precautions will be taken to ensure my safety and welfare and that I will be held responsible for the payment of medical and/or hospital accounts where applicable.
As far as I am aware I am physically capable of participating in the said sporting activity and I am good health.
Please state aspects that the staff should be aware of, e.g. allergies, tendency towards abnormal bleeding, epilepsy, diabetes, recent injury, relevant surgery, routine medication, etc.
Please note the following information:
___________________________________________________________________
___________________________________________________________________
Participants Age: ____________________________
Participants Cell: ____________________________
Participants Tel: ______________________________
Participants Banking Acc No: _____________________
Bank name:_______________________
BC:__________________________
Type of account: _______________________________
Bank tel: _________________________
The following information is essential in case of medical treatment or hospitalisation:
PERSON TO CONTACT IN CASE OF AN EMERGENCY:
Name___________________________________
Cell: ___________________________________
tel. W
tel. H
PARTICIPANTS EMPLOYER:
Name: _________________________
address: _________________________________
tel.
PARTICIPANTS MEDICAL AID FUND:
Name: _________________________
Membership No: ___________________________
tel.
PARTICIPANTS FAMILY DOCTOR:
Name: _________________________
tel. W:__________________________
tel. H:__________________________
SIGNATURE OF PARTICIPANT / GUARDIAN:_______________
DATE:____________ I.D. NUMBER: ________________________________
PLACE:____________
SIGNATURE OF WITNESS:___________________
DATE:____________ I.D. NUMBER: _______________________________ PLACE
I,___________ __________________________________ [Full name and surname], being of legal age, hereby give consent to participate in the sporting activities of Central Gauteng Schools Water Polo and SA Schools Water Polo ("the Club"), and to go on approved Club tours and excursions related to such sporting activities.
I hereby indemnify and hold the Club, its agents, representatives, coaches and managers harmless against any claim or demand arising from the death of, or injury to, myself or any loss of or damage to property, financial status, of whatsoever nature and howsoever sustained, including consequential loss, arising from or occasioned by my participation, in any such sporting activities and/or such tours and excursions.
I agree that, if in the opinion of the Chairperson of the Club or his delegated deputy, an emergency has arisen and medical treatment be deemed necessary for myself, the Chairperson of the Club or his delegated deputy shall have the authority (which is hereby delegated to the extent such delegation may be required) to consent to such medical treatment, including surgical intervention, on my behalf.
I accept that reasonable precautions will be taken to ensure my safety and welfare and that I will be held responsible for the payment of medical and/or hospital accounts where applicable.
As far as I am aware I am physically capable of participating in the said sporting activity and I am good health.
Please state aspects that the staff should be aware of, e.g. allergies, tendency towards abnormal bleeding, epilepsy, diabetes, recent injury, relevant surgery, routine medication, etc.
Please note the following information:
___________________________________________________________________
___________________________________________________________________
Participants Age: ____________________________
Participants Cell: ____________________________
Participants Tel: ______________________________
Participants Banking Acc No: _____________________
Bank name:_______________________
BC:__________________________
Type of account: _______________________________
Bank tel: _________________________
The following information is essential in case of medical treatment or hospitalisation:
PERSON TO CONTACT IN CASE OF AN EMERGENCY:
Name___________________________________
Cell: ___________________________________
tel. W
tel. H
PARTICIPANTS EMPLOYER:
Name: _________________________
address: _________________________________
tel.
PARTICIPANTS MEDICAL AID FUND:
Name: _________________________
Membership No: ___________________________
tel.
PARTICIPANTS FAMILY DOCTOR:
Name: _________________________
tel. W:__________________________
tel. H:__________________________
SIGNATURE OF PARTICIPANT / GUARDIAN:_______________
DATE:____________ I.D. NUMBER: ________________________________
PLACE:____________
SIGNATURE OF WITNESS:___________________
DATE:____________ I.D. NUMBER: _______________________________ PLACE
Staff Letter of Appointment
LETTER OF APPOINTMENT
Central Gauteng Schools Water Polo take pleasure in confirming the amateur appointment of:
__________________________________________________________
In the position of ________________________ of the under _______ boys / girls team for
the year __________
subject to the following conditions;
as laid out in this letter,
the National Educators Code of Conduct and,
the Central Gauteng Schools Water Polo Code of Conduct and,
the SA Schools Water Polo Code of Conduct.
Central Gauteng Schools Water Polo take pleasure in confirming the amateur appointment of:
__________________________________________________________
In the position of ________________________ of the under _______ boys / girls team for
the year __________
subject to the following conditions;
as laid out in this letter,
the National Educators Code of Conduct and,
the Central Gauteng Schools Water Polo Code of Conduct and,
the SA Schools Water Polo Code of Conduct.
Conditions:
1.
You will conduct yourself at all times in an exemplary manner when conducting your duties as coach or manager and not cause any action or comment to bring Central Gauteng Schools Water Polo into disrepute.
You will conduct yourself at all times in an exemplary manner when conducting your duties as coach or manager and not cause any action or comment to bring Central Gauteng Schools Water Polo into disrepute.
2.
That you will at all times act “In Loco Parentis” as to which is in the best interest of the player’s under your charge, above any other consideration.
3.
That you will consider yourself as representing Central Gauteng Schools Water Polo at all times during the SA Schools Competition including after hours activities not directly related to the competition.
4.
That you will at no time allow, condone, facilitate or leave unreported the use of alcohol, viewing of inappropriate media, tobacco, narcotics, harmful supplements and unsanctioned after hours excursions by the players under your charge.
5.
That you will partake in two clinics towards the general upliftment of water polo at developing water polo schools as well as participate in the trials process and pre season preparation of the players.
6.
That you consent and understand that all actions that you undertake are for your personal liability and especially so in the event of negligence, and that your Central Gauteng Schools Water Polo appointment is of a amateur nature.
That you will at all times act “In Loco Parentis” as to which is in the best interest of the player’s under your charge, above any other consideration.
3.
That you will consider yourself as representing Central Gauteng Schools Water Polo at all times during the SA Schools Competition including after hours activities not directly related to the competition.
4.
That you will at no time allow, condone, facilitate or leave unreported the use of alcohol, viewing of inappropriate media, tobacco, narcotics, harmful supplements and unsanctioned after hours excursions by the players under your charge.
5.
That you will partake in two clinics towards the general upliftment of water polo at developing water polo schools as well as participate in the trials process and pre season preparation of the players.
6.
That you consent and understand that all actions that you undertake are for your personal liability and especially so in the event of negligence, and that your Central Gauteng Schools Water Polo appointment is of a amateur nature.
Appointee's Full Name: ________________________ Signature:_________________
Vice Chairperson: Signature:_________________
Chairperson: Signature:_________________
Date: ___________________ Place:________________
CGSWP Provincial Trials – Players Entry Form
GSWP PROVINCIAL TRIALS – PLAYERS ENTRY FORM
(Girls entries can be emailed to fiona.cullen@vodamail.co.za)
Name:_________________________________________________________
PLEASE CIRCLE / HIGHLIGHT ONLY ONE OPTION IN EACH ROW (Questions 1 - 14):
DO NOT LEAVE ANY UNANSWERED QUESTIONS OR SPACES!
1) I am a: Male Female
2) I was born in: 1992 1993 1994 1995 1996 1997 1998 1999
3) I am trying out for the following provincial side: U/13 U/14 U15 U/16 U/19
4) My 1st choice position is: centre forward centre back wing driver keeper
5) My 2nd choice position is: centre forward centre back wing driver keeper
6) I have been selected for a provincial water polo side before: None B side A Side
7) I have played for a provincial team for the following years: 0 1 2 3 4 5
8) I am of the following ethnicity: White Black Coloured Indian Chinese Other
9) I play for a Gauteng Club side: yes no Name of club:_____________________
10) I am registered with Swim SA through my: swimming club water polo club school
11) I have paid my trials fee by: electronic transfer or cash on trial day (150)
NB! you are required to bring your proof of payment to the trials.
12) This entry was handed in on the following date_____________ and is: early late
13) I have paid in: R50 R150
PLEASE PRINT THE INFORMATION BELOW IN CAPITAL BLOCK LETTERS:
PLAYER:
Surname:______________________________________(NB check spelling!)
Full Name:_____________________________________ (NB check spelling!)
Date of Birth:__________________________ ID Number: _______________________
Player cellular:_________________________
Player email:__________________________
PARENTS
Residential Address:_________________________________________________________
Postal Address:_____________________________________________________________
Cell Number Father:__________________________________________________________
Cell Number Mother:_________________________________________________________
E-mail Father:______________________________________________________________
E-Mail Mother:______________________________________________________________
Fax number:________________________________________________________________
SCHOOL
Name of School:_____________________________________________________________
Tel number of school:_________________________________________________________
Fax number of school:_________________________________________________________
E-mail address of school:______________________________________________________
Name of school coach:________________________________________________________
Cell of school coach:__________________________________________________________
MEDICAL
Name of medical aid:_________________________________________
Medical aid number: __________________________________________
Tel number of medical aid (emergency authorization)__________________
Allergies:___________________________________________________
Dietary requirements:__________________________________________
Important Medical info:__________________________________________
Name of family doctor:_____________________________
Cell/tel of family doctor:_____________________________
ADMIN (to be completed by GSWP)
Amount paid to GSWP: R50 R150
Proof of payment received: yes no
GSWP Person who received payment:_____________________
Player Trials number allocated:___________________
Gauteng Water Polo Association's Bank Account:
BANK: Standard Bank
Account Numer: 000199044
Branch Code: 000205 or 00020500
Your reference: Initials, Surname, Age and Gender
Example: RM Smith U19 G
(Note: Please add an additional R10 for cash deposits)
(Updated June 2010, all information is treated as highly private and will not be given to any thrid parties)
(Boys entries can be email to ramseyg@stdavids.co.za)(Girls entries can be emailed to fiona.cullen@vodamail.co.za)
Name:_________________________________________________________
PLEASE CIRCLE / HIGHLIGHT ONLY ONE OPTION IN EACH ROW (Questions 1 - 14):
DO NOT LEAVE ANY UNANSWERED QUESTIONS OR SPACES!
1) I am a: Male Female
2) I was born in: 1992 1993 1994 1995 1996 1997 1998 1999
3) I am trying out for the following provincial side: U/13 U/14 U15 U/16 U/19
4) My 1st choice position is: centre forward centre back wing driver keeper
5) My 2nd choice position is: centre forward centre back wing driver keeper
6) I have been selected for a provincial water polo side before: None B side A Side
7) I have played for a provincial team for the following years: 0 1 2 3 4 5
8) I am of the following ethnicity: White Black Coloured Indian Chinese Other
9) I play for a Gauteng Club side: yes no Name of club:_____________________
10) I am registered with Swim SA through my: swimming club water polo club school
11) I have paid my trials fee by: electronic transfer or cash on trial day (150)
NB! you are required to bring your proof of payment to the trials.
12) This entry was handed in on the following date_____________ and is: early late
13) I have paid in: R50 R150
PLEASE PRINT THE INFORMATION BELOW IN CAPITAL BLOCK LETTERS:
PLAYER:
Surname:______________________________________(NB check spelling!)
Full Name:_____________________________________ (NB check spelling!)
Date of Birth:__________________________ ID Number: _______________________
Player cellular:_________________________
Player email:__________________________
PARENTS
Residential Address:_________________________________________________________
Postal Address:_____________________________________________________________
Cell Number Father:__________________________________________________________
Cell Number Mother:_________________________________________________________
E-mail Father:______________________________________________________________
E-Mail Mother:______________________________________________________________
Fax number:________________________________________________________________
SCHOOL
Name of School:_____________________________________________________________
Tel number of school:_________________________________________________________
Fax number of school:_________________________________________________________
E-mail address of school:______________________________________________________
Name of school coach:________________________________________________________
Cell of school coach:__________________________________________________________
MEDICAL
Name of medical aid:_________________________________________
Medical aid number: __________________________________________
Tel number of medical aid (emergency authorization)__________________
Allergies:___________________________________________________
Dietary requirements:__________________________________________
Important Medical info:__________________________________________
Name of family doctor:_____________________________
Cell/tel of family doctor:_____________________________
ADMIN (to be completed by GSWP)
Amount paid to GSWP: R50 R150
Proof of payment received: yes no
GSWP Person who received payment:_____________________
Player Trials number allocated:___________________
Gauteng Water Polo Association's Bank Account:
BANK: Standard Bank
Account Numer: 000199044
Branch Code: 000205 or 00020500
Your reference: Initials, Surname, Age and Gender
Example: RM Smith U19 G
(Note: Please add an additional R10 for cash deposits)
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