Membership Application Form2016/2017

Membership Renewal

Membership Upgrade

Transfer (Previous Club (______MUST provide member number *______)

Brand new member (if you have been with any club within Australia you must tick Transfer)

(Please tick one)

PERSONAL INFORMATION

(* indicate required field information)

Title* Mr Mrs Master Ms Miss

Family Name* ______First Names* ______

Address* ______

Occupation ______

CONTACT DETAILS

Please fill out at least one phone number

Phone (_____) ______Mobile ______

Email Address: ______

MEMBER DETAILS

Date of Birth*: ______/______/______(dd/mm/yyyy) Gender* (please tick) Male Female

Has the club sighted your birth certificate? Yes No

If not born in Australia has Club Sighted your Australian Citizenship Yes No

Medical Conditions/ Allergies? ______

Are you Aboriginal/ Torres Strait Islander? Yes No

Do you belong to another Swimming Federation ______

EMERGENCY CONTACT

Emergency Contact Person: ______

Emergency Contact Phone Number*: ______

MEMBERSHIP SUBSCRIPTION TYPE

(Please tick one of the following)

Competitive Swimmer- A member who competes against members of other clubs

Over 8 years Under 8 years Under 7 years

Recreational Swimmer- A member who swims within the club only and does not compete against other clubs

Over 8 years Under 8 Years

Coach- Qualified coaches who are ASCTA members

Parent Member- A parent or guardian of a swimming member

Technical Official- Must hold at least ONE Swimming Australian Technical Official qualification

Non-Swimmer- all other members e.g. Club Committee members who are NOT parents or guardians of a swimming member

Club Life Member Region Life Member State Life Member

I agree that I have been made aware of and will be bound by:

The by-laws of the Club and the information found in the current Club handbook
The rules, regulations and policies of Swimming Queensland
The rules of Swimming Australia’s Member Protection Policy and Codes of Behaviour
To wear the Club swimming cap when representing the Club in nominated carnivals
To allow the Club to use photos taken at club night and carnivals for promotional purposes in the media
In order to be offered financial assistance at any national level of competition, the member or parent must assist or be involved with fundraising activities throughout the year.

DECLARATION 1

I have read, understood, acknowledge and agree to the above declaration.

Signature (Member) ______Date _____/______/______

DECLARATION 2

Parent/Legal Guardian Consent (in respect to an applicant under the age of 18 years)

1. Where the applicant is under 18 years of age this form must be endorsed by the applicant’s parent or legal guardian.

2. I have read, understood, acknowledge and agree to the declarations above and I warrant that all information provided is true and correct.

3. I, as the Parent or Guardian of the applicant, expressly agree to accept responsibility for the applicant’s behaviour and agree to personally accept the conditions set out in the membership application and declaration.

If under 18 Parent / Guardian Signature ______Date _____/______/______

I enclose $ ……………… for one year’s membership subscription 1st July 2016 – 30th June 2017.

 I have transferred funds to Flyers Swimming Club BSB: 638-070 Account Number: 9210482

Flyers policy is to make payment for monthly training fees by direct debit. Forms available from club Treasurer or Registrar.