Maccabi Athletic Club
Registration Form for 2016 – 2017
Membership Type (Age as at 31st December 2016)
Junior (Under 14, 16, 18, 20) Track and Field Competing Member $230
Junior Cross Country Competing Member $230
Junior Track & Field & Cross Country Competing Member $290
Open Track and Field Competition Competing Member $325
Open Cross Country Competition Competing Member $325
Open Track & Field & Cross Country Competing Member $400
Junior (up to 19 years old) Associate/Training/ Recreational Runner $120
Open Associate/Training/ Recreational Runner $120
Competition Top XS / S / M / L / XL (Circle size) $45
Friend of The Club $100
Membership Fees Include Affiliation Fees With Maccabi Victoria And Athletics Victoria and the provision of Coaching. This membership expires on the 1st of April 2017
Name:…………………………………………………………………..
Address:…………………………………………………………………………………………………..
Postcode:………………
Telephone No. – Mobile:……………………………….. Other:……………………………
Email:………………………………………………………………………………………..
Date Of Birth: ……………………….. Occupation/School:………………………………….
Emergency Contact Name:………………………………………..
Emergency Contact Number:……………………………………
Please Provide Details of Any Pre-Existing Illness or Medical Conditions
………………………………………………………………………………………………………
Payments Must Be Made Before the Member Will Be Registered –
PAYMENT METHODS
- Completed forms with cheque made payable to Maccabi Athletic Club should be sent to;
Maccabi Athletic Club 197 Balaclava Road Caulfield North Vic 3161
- Electronically to the following Account: Maccabi Athletic Club Inc: BSB: 633000 Acc. No.144150570. Please leave your surname as the transfer description
This form must then be posted to the above address, faxed to (03) 8534 0050 or emailed to
CONDITIONS OF MEMBERSHIP
- Membership of the Maccabi Athletic Club Inc. involves an agreement to comply with the direction of the club’s coaches and officials.
- Membership of the Maccabi Athletic Club Inc. involves an agreement to comply with the Rules of Athletics Victoria
- Membership of the Maccabi Athletic Club Inc. involves an agreement to permit a club official to obtain medical treatment for the member should that official deem it necessary.
- Membership of the Maccabi Athletic Club Inc. involves an agreement to advise a club official of any current medical condition and any special instructions that the club should be aware of in the case of medical treatment being required.
- Membership of the Maccabi Athletic Club Inc. involves an agreement to assist as an official or work in the canteen or to organize another person to do so on their behalf.
- Unless the club is advised otherwise membership to this club involves agreement that member’s photos taken during training or competition may be used in normal club promotional material and it also involves agreement that the email address provided may be used in the club’s database for all club correspondence.
Declaration
‘I do not have any criminal convictions or findings of guilt for offences involving sexual activity, act of indecency, child abuse or child pornography. I do not have any criminal charge pending before the courts. I have not had any disciplinary proceedings brought against me by an employer, sporting organization or similar body involving child abuse, sexual misconduct or harassment, acts of violence, intimidation or other forms of harassment.’
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I apply for membership in the category indicated above and agree to the conditions of membership above and I make the declaration above required by Athletics Victoria.
Signed ...... Date: ......
Where the athlete is younger than 18 a parent is to sign below indicating acceptance of the above conditions.
Signed ...... Date: ......
For further information or clarification please contact Len Bogatin on;
M. 0411 512 404 or email