Application for Membership/Renewal 2015/2016

GAWLER AMATEUR SWIMMING CLUB Affiliated with Swimming SA

Application for Membership/Renewal 2015/2016

I hereby request application for membership to the Gawler Amateur Swimming Club Inc. - See declaration on reverse side.

New Member Yes/No Australian Citizen Yes /No

First Name…………………………………………………Surname……………………………………………………………….

Middle Name…………………………………………….Gender Male Female

DateBirth…………./…………../……….Address…………………………………………………………………………………………………

…………………………………………...Post Code…………..(H)…………………………(M)………………………………………………..

Email address…………………………………………………………Previous Club…………………………………Year……………….….

MEMBERSHIP INFORMATION

SwimmerParent/Guardian Second Swimmer Third Swimmer Life Club Member

Other Info Coach ASCTA NO………………Administrator Technical Official

Swimmer with DisabilityAsthmatic Year Book)

Indigenous MemberNon English Speaking

Emergency Contact Name………………………Relationship………………………Telephone (H)………………. ..

(M)………………………………

Note - Parents of children under 15 years are required to supervise their child whilst swimming

MEDICAL INFORMATION

Convulsions/Seizures Yes/NoAsthma/Respiratory conditionsYes/No Heart condition Yes/No

DiabetesYes/NoVision/Hearing ProblemsYes/NoAllergies Yes/No

Other……………………………………………………………...If answered yes please provide details of treatment or medication ……………………………………………………………..……………………………………………………………………………………

I authorise the Coach or nominated First Aider to obtain any legally qualified medical assistance deemed necessary and I agree to pay any expenses incurred as a result of such medical emergency. (To be signed by parent or guardian of child under 18 years).

Signed ...... …………..…………………………………Print Name………………………………………………………………………

Direct Debit Payment Option - G.A.S.C. BSB 035075 A/N 400148 Please nominate member surname on deposit

------Club Use Only

Membership Accepted Yes/No On date …….…………… Fees Received Club $ ……………Swim SA $ ......

Water Space $...... Year book payment… $………………… Receipt No(s)......

Years Membership ……………… SwimmingSA card received on ………….. Entered COL……………… …………..

Declaration:

I agree to be bound by the, accepted Constitution and By-laws booklet in force for the government and working of the said Club.
Membership to the Club is not automatically granted and this Application must still be approved of, by the Management Committee at their next meeting before membership is awarded.

I acknowledge the need to help with the running of club activities such as carnivals, fundraising, time trials etc. and will endeavour to make myself available to do so as requested by the Club Officials.

I acknowledge that the acceptance of this application for registration by Swimming SA Inc. will operate as an agreement binding me to abide by all the provisions of the Rules, Regulations and Codes of Conduct of Swimming SA Inc. and to accept and enforce all its decisions and to be bound by the constitution, rules and by-laws (as amended from time to time) of Swimming SA, Swimming Australia Limited and FINA.

I consent to images being taken of me during club activities to be used for promotional and training purposes only.

I authorise Swimming SA Inc. to use and disclose to related and relevant bodies any of my personal information that may be necessary to implement the rules, regulations and policies referred to above or as otherwise required by State and Commonwealth law.

I agree / I do not agree (please delete as applicable) to have my name, photograph and/or results published in official programmes, newsletters and/or websites.

Fitness to Participate: I declare that I am and must continue to be medically and physically fit and able to participate in any Swimming SA activity. I am not and must not be a danger to myself or to the health and safety of others. I will immediately notify Swimming SA in writing through my Club of any change to my fitness and ability to participate. I understand and accept that Swimming SA will continue to rely upon this declaration as evidence of my fitness and ability to participate.

I acknowledge and agree that the information will be disclosed to my club and Swimming SA and will only be used for the Objects of the Club and Swimming SA and to provide me with membership services. I understand that I will be able to access my information through my Club. If the information is not provided, my membership may be rejected.

I have read, understood, acknowledge and agree to the above declaration. I acknowledge that if my application for membership is successful I will be entitled to all benefits, advantages, privileges and services of Swimming SA membership.

Signature…………………………………………………………………………Date…………………………………
(Form must be signed by a Parent or Legal Guardian if applicant is under the age of 18 years)
Name of Parent or Legal Guardian (if applicable)…………………………………………………………………….

------Online Newsletters:
I would like to receive my GASC newsletters and flyers by Email please. (Just fill out once per family if req’d)

Name…………………………………………………..

Email Address……………………………………………………………………