2016 Student Membership Application Form

Please use the following table as your checklist. ESSA will not assess incomplete applications. / Application page reference / Tick when completed
BEFORE SUBMITTING THIS APPLICATION FORM PLEASE READ AND COMPLETE THE FOLLOWING INFORMATION
1. Complete personal details (Section A). / Page 2
2. Complete personal declarations (Section C). / Page 3
3. List university qualifications achieved and incomplete (Section D). / Page 3
4. Sign ESSA Declarations / Page 4
5. Enclose a clear photocopy of your current student identification card. / ATTACH TO APPLICATION
Send application form to:
Exercise & Sports Science Australia (ESSA)
The Assessment Team
Locked Bag 102
Albion DC QLD 4010

Please note: Applications will not be assessed until a complete application and supporting documentation has been received by the ESSA National Office.

Please allow 15 working days (from the date of your complete application being received) for your application to be assessed and processed.

Section A – Personal details

Title Given names Surname

Email DOB
*This is required for your website login
Are you of Aboriginal or Torres Strait Islander origin? Yes No
How did you find out about ESSA membership?
ESSA website Colleague Employer University Other

Address
Town/Suburb State Postcode
Phone Fax
Work address (if applicable to exercise and sports science)

Address
Town/Suburb State Postcode
Phone Fax
Mobile
Current employment

Previous position/title

Privacy Statement:

Exercise & Sports Science Australia acknowledges and respects the privacy of its members. All information provided on this form is subject to ESSA’s Privacy Policy. Details of this policy can be viewed on ESSA’s website www.essa.org.au. ESSA uses and discloses personal information only for our primary functions or a directly related purpose e.g. release of information to organisations including Medicare, Department of Veterans’ Affairs, private health funds, Workcover, National Health Services Directory and relevant condition organisations e.g. Arthritis Australia, and release of information via the Find an AEP search function on ESSA’s website. You have the right of access to and alteration of your personal information in accordance with the Privacy Act. Please direct any enquiries you have in relation to this matter to ESSA’s Executive Officer on ph. 07 3862 4122.

IF YOU DO NOT WISH FOR YOUR INFORMATION TO BE DISCLOSED PLEASE CHECK HERE

Section B – Personal declarations
a) I certify that the information supplied on and with this form is true and correct.

Applicant’s signature Date
b) If accepted as a student member of the association I agree to abide by the ESSA Code of Professional Conduct and Ethical Practice.

Applicant’s signature Date
Section C - University qualifications
List only University degrees awarded and being undertaken from University institutions.
Completed degree/s / University / Year completed
Incomplete degree/s / University / Year commenced

Please attach evidence of your current university enrolment with a clear copy of your current student ID card that is valid for the entirety of 2016 or an enrolment notice that confirms your 2016 student status.

ESSA Declarations

By submitting this application I authorise and acknowledge the following:

a) I certify that the information supplied on and with this form is true and correct.

Applicant’s signature Date

b)  If accepted as an Exercise & Sports Science Australia member and or an accredited professional I agree to abide by the Exercise & Sports Science Australia Code of Professional Conduct and Ethical Practice.

Applicant’s signature Date

c)  If accepted as an Exercise & Sports Science Australia member and/or an accredited professional I confirm that I am a fit and proper person by acknowledging the following:

- I have not been charged with or have any prior convictions for a serious criminal offence, sexual assault, fraud, or other offence of dishonesty;

- I have not been and am not currently under investigation, the subject of complaint, disciplinary proceedings or adverse findings as to fitness to practice by any international regulatory body having jurisdiction over me or any industry in which I have been employed;

- I possess the necessary physical and mental health to deliver a service safely and competently to the public.

Applicant’s signature Date

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