APPLICATIONFORMEMBERSHIP20/20SEASON
1.CLUBNAME MIAMI BEACHSLSC
2. GENERALDETAILS
IherebyapplyformembershipofSLSA. Ihaveread,understood,acknowledgeandagreetothedeclarationandapplicationoverleaf. Ihavesignedthatdeclarationand application.
INITIALMEMBERSHIPRENEWING
TITLE (Mr,Mrs,Ms,etc)FIRSTNAME SECONDINITIAL LASTNAME
MALEFEMALEDATEOFBIRTH / / OCCUPATION
ADDRESS POSTCODE PHONE: HOME BUSINESS FAX MOBILE PREFERREDCONTACTNUMBERNOB/ H/M EMAIL Drivers License LicenseNumber LicenseType Exp Date ShirtSize(PleaseCircle) 6 /8 / 10/ 12/ 14/XS/S /M /L/ XL/2XL/ 3XL/4XL /5XL
ShortSize(PleaseCircle)S /M/L / XL/ 2XL/3XL/ 4XL/5XLIdonotwishtoreceiveemail/sms communication
3.MEMBERSHIPDETAILS APPLIEDFOR– SUBJECTTOCLUBENDORSEMENT (Tickoneboxonly)
PROBATIONARY……………………………….. / AWARDMEMBER…………..… / ASSOCIATE………………JUNIORACTIVITYMEMBER(5-13 years)……… / RESERVEACTIVE………….… / LIFE MEMBER……………
CADETMEMBER(13-15 years)………………… / LONGSERVICE………….…… / GENERAL..………………..
ACTIVE(15-18 years)…………………………… / PASTACTIVE….………….…… / HONORARY………………
ACTIVE(18 yearsandover)………………………
DateJoined CompetitiveRightswiththisclub: YESNOLockerNumber
KeyNo
MemberProtectionFormCompleted?YESNOMembershipProtectionNumber(whereapplicable)
4. OTHERSURF LIFE SAVINGCLUBMEMBERSHIPS (Pleaseattachlist if morethantwo)
SLSCSLSC
5. MEDICAL DETAILS
Ifyousuffer oryouhavesuffered fromanydiseaseoranyphysicalormentaldisability(eg,epilepsy,diabetesorany permanentdisabilitytoalimb,eyeorear) likelytoaffectyourefficiencyasaClubmember,itmayaffectyoursafetyandthesafetyofthepublic. Youshouldconsultyourmedical practitionerandSLSApriorto commencinganysurflifesaving activity.Youshouldtake partin aHepatitisBvaccinationprogram.
HAVEYOUREADTHISSECTION?YESNO
6.EMERGENCY CONTACT
FIRSTNAME LASTNAME
RELATIONSHIP_ADDRESS POSTCODE
PHONE:HOME BUSINESS FAX: MOBILE:
7. BACKGROUND DETAILSAreyoufromaculturallyandlinguisticallydiverse background? / YES / NO / CulturalBackground
Doyouuseanylanguages otherthanEnglishin yourhome? / YES / NO / SecondLanguage
AreyouofAboriginaldescent?YESNOAreyouofTorres StraitIslanderdescent?YESNO
8. DECLARATIONIhaveread, understood,acknowledge andagreeto thedeclarationandapplicationand conditionsof membershipoverleaf. Ihavesignedthatdeclarationandapplication.Iwarrantthatallinformationprovided is trueandcorrect.
SIGNATURE DATE:
9. PARENT/LEGAL GUARDIANCONSENT (IN RESPECTTO ANAPPLICANTUNDER THEAGEOF 18YEARS)
I haveread,understood,acknowledgeandagreetothedeclarationandapplicationandconditionsofmembershipoverleaf andIpersonallyconsenttothedeclaration andapplicationforMembershipoftheapplicant.
FIRSTNAME LAST NAME SIGNATURE DATE
10. OFFICE USE ONLY
DateApplicationreceived / / Amountpaid:$Receipt No.
Accepted/ RejectedbyClubManagement–Date / / SignatureofClub Officer
MembershipCategoryallocated
Capitation/MembershipNo. IDCited–Type Date Entered / /
Note:DOBcan onlybe amendedwiththeapprovalofyourStateCentre afterinitialentry
SLSAMEMBERSHIPAPPLICATIONDECLARATION
I[insert name]…………………………………………of[insert address]…………………………………
herebyapply for membership ofSLSA.In consideration ofmy application for membership beingaccepted I acknowledgeand agreethat:
1.In thismembership declaration:
“Claim”meansand includesanyaction, suit, proceeding, claim, demand, damage,penalty, cost orexpensehowever arisingincluding but not limited to negligenceBUT doesNOT includea claim against SLSA by anyperson entitled to makea claim under a relevant SLSA insurancepolicyor under theSLSA Constitution or SLSA Regulations.
“SLSA” meansSurfLifeSavingAustralia Limited.
“SLS Organisations” meansand includesSLSA, itssubsidiaries, itsmembers(includingStateCentres& Clubs), Branchesand their respectivedirectors, officers, members, servantsor agents.
“SLS Activities”meansperformingor participatingin any capacity in any activity authorised or recognised by SLSA.
2.If my application for membership is accepted I will be a member of [Insert Club]……………………………… SLSC, [insert Branch if relevant]…………………………….,[insertState]…………………………….StateCentreSLSA. Iacknowledgemyapplicationwillbedeemedtobe accepteduponmyparticipationinSLSActivitiesandIacknowledgethatIwillbeboundbyandagreetocomplywiththeconstitutions, regulationsandpoliciesoftheSLSOrganisations. TheserulesarenecessaryandreasonableforpromotingSLSAandsurflifesavingasa community service.
3.Warning: SLSActivitiescanbeinherentlydangerous. Iacknowledgethat IamexposedtocertainrisksduringSLSActivitiesincludingbut
not limited to physical exertion, contact with surf lifesaving equipment, body contact and surf, sea and weather conditions. I acknowledgethataccidentscanandoftendohappenwhichmayresultinmebeinginjuredoreven killed,ormypropertybeing damaged. Ihavevoluntarilyreadandunderstoodthiswarningandacceptandassume theinherentrisksinparticipatinginSLS Activities.
4.Exclusionofimpliedterms: IacknowledgethatwhereIamaconsumerofrecreationalservices,asdefinedbyanyrelevantlaw,certain termsandrightsusuallyimpliedintoacontractforthesupplyofgoodsandservicesmaybeexcluded.Iacknowledgethattheseimplied termsandrightsandanyliabilityoftheSLSOrganisations(oranyofthem)flowingfromthem,areexpresslyexcludedtotheextent possiblebylaw,bythismembershipdeclaration. Totheextentofanyliabilityarising,theliabilityoftheSLSOrganisationswill,atthe discretionoftherelevantSLSOrganisation,belimitedtotheresupplyoftheservicesorthepaymentofthecostofhavingtheservices supplied again.
5.Release &Indemnity: In consideration ofSLSA acceptingmy application for membership I:
(a)releaseandwillreleasetheSLSOrganisationsfromallClaimsthatImayhaveormayhavehadbutforthisreleasearising from or in connection with my membership and/or participation in any SLS Activities; and
(b)indemnifyandwillkeepindemnifiedtheSLSOrganisationstotheextentpermittedbylawinrespectofanyClaimbyany person arisingasa result ofor in connection with my membershipand/or participation in any SLS Activities.
6.FitnesstoParticipate: IdeclarethatIammedicallyandphysicallyfitandabletoparticipateinanySLSActivities. Iamnotandmustnot beadangertomyselfortothehealthandsafetyofothers. IwillimmediatelynotifySLSAinwritingthroughmyClubofanychangeto my medical condition, fitnessand ability to participate.
7.Privacy: IunderstandthattheinformationthatIhaveprovidedoverleafisnecessaryfortheObjectsoftheSLS Organisations. I acknowledgeandagreethattheinformationwillbedisclosedtomyClubandStateCentreandwillonlybeusedfortheObjectsofthe SLSOrganisationsandtoprovidemewithmembershipservices. IunderstandthatIwillbeabletoaccessmyinformationthroughmy Club. Iftheinformationisnotprovidedmymembershipapplicationmayberejected. IacknowledgethattheSLSOrganisationsmay alsousemypersonalinformationforthepurposesofprovidingmewithpromotionalmaterialfromSLSOrganisationsponsorsorthird parties. ImayadvisemyStateCentreifIdonotwishtoreceiveanysponsororthirdpartymaterial.Thisinformationisbeingcollected bySLSAanditmaybesharedwithotherSurfLifeSavingorganisationsforthepurposesoffulfillingtheSurfLifeSavingorganisations' objectives.Youareabletogainaccesstoanyinformationheld.Iagreethatduringthecourseofanyduty,myimage,voiceorlocation may betrackedand recorded for thepurposesofSLSA operational safety.
8.Useofimage:IconsenttotherelevantSLSOrganisation(s)ofwhichIamamember,usingmyname,image,likeness andalsomy performanceinorofanySLSActivityatanytimetopromotetheObjectsoftherelevantSLSOrganisation(s),byanyformofmedia.I waiveany rightsI might haveto or in such useofmy name, imageor likenessby therelevant SLSOrganisation(s).
9.Ihaveprovidedtheinformationrequiredoverleafandsignedbothsidesofthisform. Iwarrantthatallinformationprovidedistrue andcorrect. Iacknowledgethatthismembershipdeclarationcannotbeamended. IfIdoamenditmyapplicationwillbenullandvoid and cannot beaccepted by SLSA.
10. Severance: Ifanyprovisionofthismembership declarationisinvalidor unenforceableinanyjurisdiction, thephraseorclauseistobe readdownforthepurposeofthatjurisdiction,ifpossible,soastobevalidandenforceable. Ifthephraseorclausecannotbesoread downitwillbeseveredtotheextentoftheinvalidityorunenforceabilityofitinanyotherjurisdiction. Suchseverancedoesnotaffect theremainingprovisionsofthismembership declaration or affect thevalidity orenforceability ofit in any other jurisdiction.
Ihaveread,understood,acknowledgeandagreetotheabovedeclarationincludingthewarning,exclusionofliability,releaseindemnity. I acknowledgethatifmyapplicationformembershipissuccessfulIwillbeentitledtoallbenefits,advantages,privilegesandservicesofSLSA membership.
Signed:...... Date:………………..……..Name…………………………………………………………………….……………….
NOTE:Wheretheapplicantis under18yearsofagethisformmustalsobesignedbythe applicant’sparentorlegal guardian.
I, ...... amtheparentorguardianoftheapplicant. Iauthorizeandconsenttotheapplicantundertakingthe SLSActivities. Inconsiderationoftheapplicant’smembershipbeingacceptedIexpresslyagreetoberesponsiblefortheapplicant’sbehaviour andagreetopersonallyacceptinmycapacityasparentorguardiantheterms set outinthismembershipapplicationanddeclaration includingtheprovisionbymeofareleaseandindemnityinthetermssetoutabove. InadditionIagreetobeboundbyandtocomplywith theSLSA constitution and any regulationsand policiesmadeunder it.
Parent’ssignature:...... Date: ………………..……Name: ...... ………………………………………………………..
(Where applicantunder18years ofage)