1 / 3 August, 1996
/ Diamond Valley Bushwalking Club Inc. A0010907B
PO Box 536
ELTHAM VIC 3095
Affiliated with Bushwalking Victoria
WEBSITE:

Application for Temporary Membership

Acknowledgement of Risks and Obligations by Temporary Members

______(“the Activity”)

Short description of Activity as in Program

commencing on ______(day)______(month) 20___

& concluding on ______(day)______(month) 20___

This acknowledgement applies to all activities I may undertake as a tempoary member of the Diamond Valley Bushwalking Club [the Club]. In voluntarily participating in activities of the Club, which are described to me by the Activity Leader I am aware that my participation in the activities may expose me to hazards and risks that could lead to injury, illness or death or to loss of or damage to my property. I also acknowledge that I may encounter weather conditions that could lead to hypothermia and being in locations where evacuation for medical treatment may take hours or days. In particular when participating in abseiling or above the snowline activities I am aware that these activities could expose me to additional hazards and risks described to me by the activity leader.

To minimise risks I will endeavour to ensure that:

1. each activity is within my capabilities; and

2. I am carrying food, water and equipment appropriate for the activity. In addition I will:

a) advise the Activity Leader if I am taking any medication or have any physical or other limitationthat might affect participation in the activity;

b). make every effort to remain with the rest of the party during the activity;

c). advise the Activity Leader of any concerns I am having; and

d). comply with all reasonable instructions of Club Officers and the Activity Leader.

I have read and understand the above requirements,. I have considered the risks before choosing to sign this Ackowledgement of Risks and I still wish to join the activities of the Club. I acknowledge that I will take responsibility for my own actions and that signing this form OR the payment of my subscription will be deemed as full understanding and acceptance of the above conditions.

NAME:
ADDRESS:
HOME PHONE: / MOBILE PHONE:
EMERGENCY C0NTACT NAME:
EMERGENCY CONTACT PHONE NO:
SIGNATURE:
DATE: / FEE PAID:
NOTE THIS FORM MUST BE SIGNED BY EVERY TEMPORARY MEMBER AND A TEMPORARY MEMBERSHIP FEE OF $5.00 PER PERSON PAID BEFORE COMMENCING ANY CLUB ACTIVITY. MEMBERS OF OTHER CLUBS AFFILIATED WITH BUSHWALKING AUSTRALIA ARE EXEMPT FROM THE FEE.

I ______(leaders name) having been satisfied that the above persons have fulfilled the requirements to become Temporary Members of the Club HEREBY ADMIT each of the above to Temporary Membership of Diamond Valley Bushwalking Club Inc for the above period.

(Leader’s signature)

COMMITTEE USE ONLY / FEE $5.00 PAID / EXEMPT / LEADER INITIALS
RECEIPT NUMBER / ………………. / ………… / TREASURER INITIALS

Please forward payment promptly to the Treasurer or pay into the following account:

Account Name: Diamond Valley Bushwalking Club

BSB:083-232

Account: 02 761 5451

Reference:‘Walker’s Surname’ TempMbr

May 2014