SkateNSW / SkateAustralia

2018ClubMembership

$180 (without Portal) / $200 (with Portal)

RegisteredNameofClub: / Enter Club Name here
IncorporationNumber: / Inc Number / Australian Business Number: / ABN
Discipline(s): / Artistic / Inline
Hockey / Roller
Derby / Roller
Hockey / Speed
Club contact details
Postal Address: / PO Box or Registered address
City: / State: / Post Code:
Email: / Contact name:
Website: / Phone:
Venue contact details
Venue Name: / Rink or Venue name
Physical Address: / Rink or Venue physical address
City: / State: / Post Code:
Email: / Contact name:
Website: / Phone:

We the undersigned do affirm that the information provided on this form is correct and truthful and we hereby make application to Skate Australia for club membership/renewal. We agree to abide by the rules and regulations of SA Inc during the term of the membership and agree to accept any jurisdictional committee of SA Inc. We hereby agree for the club to waiver any and all claims and rights for claims for damages we may have or acquire against SA Inc, their agents, officers and/or members. We actively foster at least one branch of roller sports by preparing skaters for proficiency tests, coaching clinics and / or competitions. All our members are members of SA Inc or have applied for membership in SA Inc. We agree to support SA Inc. in every way possible and in particular by sending representatives to Branch Committee Meetings.

Enter Name Here, Then Sign And Date / 01/01/2018
Club President / Secretary / Treasurer (circle one)
Enter Name Here, Then Sign And Date / 01/01/2018
Club President / Secretary / Treasurer (circle one)

Please note - All member benefits including insurance are invalid unless the Form is signed by two signatories from the President, Secretary or Treasurer. 2018 Club Membership Fees are inclusive of $20M Public Liability Insurance cover and Association Liability Cover, however the cover will not be endorsed or Certificate of Currency issued until this form together with the required fee and the Certificate of Incorporation is received in the State Office. All memberships expire on 31st December each year and are subject to ratification by the SA Board. Privacy Statement: Information contained on this form will be treated as confidential and SA Inc will not provide details contained in this application to any other organization except for the purpose of issuing Certificate of Currencies and /or competition information.

SkateNSW / SkateAustralia

2018ClubMembership

$180 (without Portal) / $200 (with Portal)

2018 Club Committee Members

All Committee members and branch representatives must be current Skate NSW / Skate Australia members (Associate membership or above)

President / Name / SA ID / SA Number or DOB
Secretary / Name / SA ID / SA Number or DOB
Treasurer / Name / SA ID / SA Number or DOB
Registrar / Name / SA ID / SA Number or DOB
Other / Name / SA ID / SA Number or DOB
Other / Name / SA ID / SA Number or DOB
Other / Name / SA ID / SA Number or DOB
Other / Name / SA ID / SA Number or DOB

2018 Club RevolutioniseSport Access

Please choose one of the following two options:

Database only ($180)
Access to your Clubs Membership database section.
The below hereby agree to access terms/conditions* / Full RevolutioniseSport Portal ($200)
Membership Portal and Management system including website (recommended)
Administrator 1 Name (Sign And Date Below) / Banking Information for PIN Payments (preferred)
CLUB BANK ACCOUNT NAME
01/01/2017 / CLUB BANK ACCOUNT NUMBER
Administrator 2 Name (Sign And Date Below) / CLUB BANK ACCOUNT BSB
or / club paypal registered email address
01/01/2017 / Email Club’s Membership Prices/Structure/ABN
* Database access terms/conditions attached / For self set up contact SkateNSW for instructions

2018 Club Registration Check List

Please ensure you complete and/or provide the following documentation:

Certificate of incorporation
Club constitution
Minutes of most recent Club AGM / Minutes of first meeting (for Newly registered clubs)
‘Play by the Rules’ online training course Certificate
Proof of Working With Children Check Compliance (where required)
SkateNSW Club Membership fee payment (clubs will be invoiced on receipt of Membership form)
Minimum membership of:
•8 individual Competitive (CAT1 or CAT2) members, or
•or ratio mixture of Competitive (1), Development-CAT3 (2) and/or Recreational-CAT4 (4)