MACCABI AMATEUR SWIMMING CLUB
□ New Member □ Renewal Previous/Current Club _________________________
□ Transfer □ 2nd Claim SNSW Member # _____________________
First Name ____________________________ Surname _____________________________________
Date of Birth (dd/mm/yyyy) _________________________ Gender __________
Address _______________________________________________ Suburb _______________________
Phone (H) ______________________ (M) ____________________ (W) __________________________
Email Address ________________________________________________________________________
Swimming NSW Member Declaration
1. I agree to abide by the rules, regulations and policies of Swimming NSW, Swimming Australia,
the relevant Area Swimming Association and the relevant club, including Swimming Australia’s Anti-Doping,
Member Welfare, Child Welfare and Privacy Policies (these are available at www.swimming.org.au ).
2. I authorise Swimming NSW to use, disclose or relate to any 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, photograph and results published in official
programs, newsletters, the AJN and websites.
I have read and agree to the above.
Swimmers Signature (under 18 yrs)
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 the details provided in the application and I personally consent 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 be responsible for the
applicant’s behaviour and agree to personally accept the conditions set out in this
membership application and declaration.
If under 18, My parent has read and agreed to the above
Emergency Contact Person ______________________________________________________________
Relationship to Applicant ______________________________________________
Emergency Contact Number/s ______________________________ ____________________________
MACCABI AMATEUR SWIMMING CLUB
Other Membership Details (please tick)
□ Swimmer □ Non Swimmer □ Swimmer with a disability Classification _________
□ Australian Citizen □ Asthmatic □ Other Medical (please specify) _________________
SCHEDULE OF FEES
□ Swimming NSW Membership $56 swimmer (membership covers the swimming year 1 Oct to 30 Sep annually)
□ Swimming NSW Membership $18 non swimmer (membership covers the swimming year 1 Oct to 30 Sep annually)
□ Maccabi NSW Junior Membership $25
□ Maccabi NSW Adult Membership $35
□ I am a current financial member of the following Maccabi NSW Sporting Club ___________________
□ Maccabi Amateur Swimming Club Member - Swimmer $89 □ 2nd child $69 □ 3rd child $49
□ Maccabi Amateur Swimming Club Member - Non Swimmer $35
□ Maccabi Amateur Swimming Club 2nd claim Member - Swimmer $60 (includes Maccabi NSW fee $25)
Swimmers Membership includes Team Swimming Cap
All members of MASC must register with Swimming NSW
MASC Membership covers the swimming year from 1 October to 30 September annually
Membership to NSW Maccabi applies for members without current membership to other Maccabi Sporting Clubs
PAYMENT INSTRUCTIONS: credit card only
Card Type □ Visa □ Mastercard Name on Card: ________________________________
Card Number: ____________________________________ Expires: _____________ CSV _________
I/We affirm that I/We are member/s of the Jewish Faith and agree to be bound by the rules
and code of behaviour of Maccabi Amateur Swimming Club, Maccabi NSW and Swimming NSW.
Permission is given for photographs to be taken of my child that may be used for publicity/promotion of MASC.
Signed (parent/guardian) __________________________________________
Name (printed) _________________________________________________ Date __________________
Office Use Only
SNSW Paid ________________ SNSW # ________________ Maccabi NSW Paid _______________
MASC Paid ________________ CAP Yes/No
Shirt Size________ Yes/No
Total Paid and Date ____________________________