Yeppoon Swimming Club Inc. 'Go The Sharks !'

www.yeppoonswimmingclub.org.au

MEMBERSHIP FORMS

MEMBERSHIP FORM

CLUB _____________________________________________________________________________ SEASON: 20 _______ / 20 ________

 Renewal  New Member  Upgrade  Transfer (Previous Club (__________________________________________________)

PERSONAL INFORMATION ( * compulsory information for members )

Title* Circle Mr, Mrs, Miss, Ms, First Name* _________________________________________________

Middle Name* ____________________________________________ Last Name ______________________________________________

Address* ________________________________________________________________________________________________________

Suburb* State* Postcode* ___

*At Least One Telephone Contact Number Must Be Entered

Business (_____)______________________ Private (_____)________________________ Mobile _________________________________

Emergency Contact Person* _________________________________________________________________________________________

Emergency Contact Number* ________________________________________________________________________________________

Date of Birth* ______/______/______ (dd/mm/yyy) Gender* ○Male ○Female

Email Address: ___________________________________________________________________________ Format: ○HTML ○Plain Text

Membership Subscription Type*

Competitive Swimmer: A member who competes against members of other clubs.

1st or 2nd Family Member ○3rd Family Member ○4th Family Member ○

Recreational Swimmer: A member who swims within club only, i.e: does not compete against members of other clubs.

1st or 2nd Family Member ○3rd Family Member ○4th Family Member ○

Non – Swimmer: ○(All other members e.g. Club Committee members who are not the parents/guardians of a swimming member, etc)

Parent Member: ○( The parent or guardian of a swimming member.)

Coach: ○(This membership is for qualified Coaches who are members of ASCTA.)

Technical Official: ○( To be eligible for this category you need to hold at least one SAL Technical Official qualification.)

Life Member Club: ○Life Member Region: ○Life Member State: ○

I would like to receive: ○Swimming Queensland’s Q-Swimmer (Free)

National Custom Fields:

Alternate Email Address: _____________________________________________________________________

Alternate Address(including Suburb, State & PC)_________________________________________________________________________

Medical Conditions/ Allergies/ Vaccinations? ____________________________________________________________________________

If a SWD member, what are your classifications: _________________________________________________________________________

What is your Coach’s name? _________________________________________________________________________________________

Do you belong to another Swimming Federation: _________________________________________________________________________

Australian Citizen? ○Yes ○No Asthmatic? ○Yes ○No Indigenous Member? ○Yes ○No

DECLARATION 1 Title:	Conditions of being a Member of Swimming Queensland, Affiliated Regions and Affiliated Clubs
Declaration:	1. I agree to abide by the rules, regulations and policies of Swimming Queensland, Swimming Australia, the relevant Regional Swimming Association and the relevant club, including Swimming Australia’s Anti-Doping, Member Welfare and Privacy Policies (these are available at www.swimming.org.au ). 2. I authorise Swimming Queensland to use and disclose, to related and relevant bodies, any of my personal information that may be necessary to implement the rules, regulations and policies in 1 above. I agree to have my name and results published in official programs, newsletters and websites. 3. I note that the club, as an affiliate of Swimming Queensland, has $20 million public liability insurance cover. 4. I warrant that all information provided is true and accurate.
Confirmation:	○I have read, understood, acknowledge and agree to the above declaration.

Additional Information Form (pdf)

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