PAYMENT & BOOKING FORM(please BRING to the meeting on 24 July for our records)

Runner’s Name:________________________________________ Circle whatapplies below:

Team Member Cost: (includes a $50 non refundable deposit)Includes -bus transport, accommodation, race entry, meals2 x pool entry at Hanmer, Awards Dinner and team photo. $180.00

COMPULSORY Polo Shirt (shirts from past years acceptable) (ordered online) $20.00Size: (please circle) 6 8 10 12 14 16

Optional items:Canterbury Team Training Jacket (ordered online)

Size (please circle) 4XS 3XS 2XS XS S $40.00 Measurement 1/2 Chest (cm) 4XS=45, 3XS=50, 2XS=55

Canterbury Team Shorts (ordered online)Size (please circle) 8 10 12 14 16 $25.00Measurement - Waist (lying flat, unstretched in cms) 8-52, 10-54, 12-58, 14-62Note: new short supplier for 2014

Hanmer Slides (Thursday and/or Friday - $10 per session) $10.00 / $20.00__________________________________________________________________Parents, if selected as a managerManager’s Name: ________________________________________Parent Manager Cost:Includes as above - less photo and race entry $160.00

COMPULSORY Polo Shirt: (shirts from other years acceptable)(ordered online) $20.00 Size: (please circle) Mens S M L XL 2XL 3XL 4XL 5XL

Women 8 10 12 14 16 18 20 22 24 Optional item:Canterbury Team Training Jacket (ordered online)

Size (please circle) S M L XL XXL $40.00 _________________________________________________________________

TOTAL: _______

Paid by internet/cheque/cash. Date paid ____________ Less Amount paid: _______(Please circle)

BALANCE OWING: _______Full Payment must be made by Thursday 24 July 2014 (unless other arrangements have been made) Payment can be made either directly to account 031783 0153007 05 (Please ensure you include your child’s name as a reference so that we know who has paid) or mailed to: Primary Sports Canterbury, P O Box 2606, Christchurch 8140. Please make cheques payable to: Primary Sports Canterbury Cross Country.

Cross Country Team PLEASE HAND IN THIS FORM ON 24 JulyIRXC2014 CONFIDENTIAL MEDICAL FORM AND POLICIES

STUDENT’S NAME: ...............................................................................................................

SCHOOL: ...............................................................................................................................

AGE:.......................YEAR AT SCHOOL:....................DATE OF BIRTH: .....................................

PARENTS’ NAMES: ................................................................................................................

CONTACT DAY PHONE: ........................................................................................................

CONTACT EVENING: .............................................................................................................

CELL PHONE: .......................................................................................................................

I give permission for my son/daughter __________________________ to participate in the Inter-Regional Cross Country Championships, Nelson.

I give permission for my phone number, email and address to appear on a list for shared transport purposes to and from training sessions. YES/NO

REFUND POLICYFees paid, include a non-refundable deposit of $50.00. Any other refunds will be on a case by case basis and may require the presentation of a medical certificate.

CELL PHONE POLICYWe prefer children NOT to have cell phones with them. We will let you know the cell phone numbers of their managers. Any cell phones taken will be collected in each night and redistributed the following morning. My son/daughter_______________________________ WILL/WON’T have a cell phone with them during their stay.

BEHAVIOUR POLICYI have read the event information and understand there are risks associated with the involvement in such events and these risks cannot be completely eliminated. I understand that the management will identify any foreseeable risks or hazards and implement correct management procedures to eliminate, isolate or minimise those hazards. With this in mind I agree to my child taking part in the event and acknowledge the need for them to behave responsibly. I understand that should my child not behave responsibly, they will be disciplined accordingly and may be withdrawn from any events, or the team, at the Team management discretion.

Print Name_______________________ Signed:___________________________Date:________ (Parent)

ALTERNATIVE EMERGENCY CONTACT DETAILS (Alternative to above details)

Name: ..................................................................................................................................

Relationship to student: .......................................................................................................

Day Phone: ....................… Evening Phone:.......................... Cell:.....................................

EVENT DESCRIPTION: Inter-Regional Cross Country Championships, Hanmer Springs.DATE OF EVENT: 24-16 September 2014

Is your child presently taking tablets and/or medicine? YES/NO

If YES please state the name of the medication and the dosage:………….............................

..……………………………………………………………………………………………………………………………………………

Any allergies YES/NO

If YES please state ………………………………………………………………

Comments: ……………………………………………………………………….

Last tetanus immunisation was …………………………………………………….

Dietary Requirements: YES/NO

If YES please state..........................................................................................

.......................................................................................................................................

...............................................................................................................................

Family Doctor:..............................................................................................................................

Medical Centre:............................................................................................................................

Phone..........................................................................................................................................

It is important that you disclose ANY medical conditions that may affect your child’s safety.

Please circle and comment if need to:

Bed wetting_______________________________________________________________

Fits of any kind_____________________________________________________________

Heart condition_____________________________________________________________

Dizzy spells_______________________________________________________________

Sleep walking______________________________________________________________

Asthma___________________________________________________________________

Blackouts_________________________________________________________________

Migraine__________________________________________________________________

Travel Sickness____________________________________________________________

Other (please specify)_______________________________________________________

Allergies to: (please circle)

Penicillin Drugs Insects Other (please specify)

Comments_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is this the first time your child has been away from home? YES/NO

I have disclosed all medical conditions that may affect my child’s safety. I understand that it is the discretion of the team management to administer or seek medical attention for my child as required.

Print Name......................................................................................

Signed:.............................................................................................

Date:...............................................................................................PLEASE HAND IN THIS FORM ON 24 JulyTHIS REPORT IS TO ASSIST US IN CASE OF ANY EVENTUALITY. ALL INFORMATION IS HELD IN CONFIDENCE.