Member Application Form 2017

MEMBER APPLICATION FORM 2017

NEW MEMBER RENEWAL (Mark with an x)

WPA LICENCE NUMBER

Picture may be emailed to:

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PERSONAL INFORMATION

SURNAME

FIRST NAME(S) TITLE (MR, MRS, MISS, DR)

IDENTITY NUMBER

OCCUPATION

HOME LANGUAGE

PHYSICAL ADDRESS POSTAL ADDRESS

CONTACT NUMBERS

E-MAIL ADDRESS

MEDICAL AID DETAILS (If applicable)

PREVIOUS CLUB NAME (if applicable)

Please list any medical conditions and/or injuries

NEXT OF KIN DETAILS (Please provide two)

MEMBERSHIP FEES

(Mark with an x)

R270 (Club membership fee + WPA licence fee)

Junior (13-18years): R30 WPA Licence fee

Pensioner (65years as of 1/1/2017 and older): R140 WPA Licence fee

Payment method:

Direct deposit

EFT

Banking Details

Bank: Nedbank

Account Name: OFAC Race Account

Branch: Kenilworth

Branch Code: 198765

Account Number: 1073544958

Reference: “Licence” Name and Surname

Please return the signed and completed form with your proof of payment to Aadiela Kimmie via email: .

By signing this form, I hereby declare that the above information given is true and correct. I further declare and agree:

To abide by the constitution of Ommiedraai Friends Athletic Club.

To abide by the rules and regulations of ASA (Athletics South Africa) and WPA (Western Province Athletics).

To indemnify Ommiedraai Friends Athletic Club, its coaches, officers and assistants against all and any action of whatever nature for any loss, damage, illness or injuries that may be sustained or arise out of my participation in any training session, race or social event.

That it is my responsibility to ensure that I am medically fit to train and compete in any race.

To at all times behave in such a manner so as not to bring the name of Ommiedraai Friends Athletic Club into disrepute

To at all times inform Ommiedraai Friends Athletic Club of any change in medical conditions and any other relevant information.

Signature: ...... Date: ......

OMMIEDRAAI EXCO

M.S Allie (President/Race director), F. Salie (Chairman), F. Majiet (Vice Chairman)

W. Samsodien (Secretary) S. Alexander (Vice Secretary), A. Ebrahim (Treasurer), M. Salie (Vice Treasurer)

F. Ebrahim (Events Coordinator), R. Christians (Registrations officer), F. Coe (Race Secretary/Registrations)

F. Isaacs (Trustee), A. Kimmie (Additional member/Registrations)