CORK POLOCROSSE CLUB MEMBERSHIP FORM 2012

corkpolocrosse@gmail.com
PERSONAL DETAILS
Name: ..............
Address: ...
..
Date of Birth:
Phone: (home) . (mobile)
Email: ..
HORSE INFORMATION

If yes, is/would it be suitable/available for polocrosse? ...................... Yes

Do you own a horse? ............................................................................ Yes

No

No

POLOCROSSE EXPERIENCE

Have you played polocrosse before? .................................................... Yes

No
If yes, where have you played? .......................................................................................

Do you have an Irish Polocrosse Association grading? ....................... Yes

No
If yes, how many points do you have? ............................................................................

EMERGENCY CONTACT DETAILS

Please indicate below the person(s) who should be contacted in the event of an incident/accident:
Emergency Contact Name(s): .
Emergency Contact Number(s):
AGREEMENT AND SIGNATURE
I (insert name)_______________ understand polocrosse is a risk sport and Cork Polocrosse Club accepts no
responsibility for any injury or loss to players, horses or property during the course of training, tournaments
or other events which the club may partake in. I agree to abide by the rules policies and procedures of the
CORK POLOCROSSE CLUB as outlined in the club constitution, any amendments to such, and any other
rules/regulations as may be put in place by the CORK POLOCROSSE CLUB committee.
Signature: .. Date: .
CONSENT (Members under 18 years of age only to be completed by parent/legal guardian)
By signing below I, (name) , being the parent/legal guardian
of (name) ., agree to his/her membership of the CORK POLOCROSSE CLUB and
to him/her participating in training , tournaments or other events which the club may partake in. I agree that
Cork Polocrosse Club bears no responsibility for junior members travelling to/from tournaments or while
attending tournaments.
Signature Parent/Guardian:

Date: ..

Cork Polocrosse 2012 Membership Fees

Senior:

120

Junior:

100

Temporary Membership Fee:

5 per training session