MASC membership form - Annual 2013 - Maccabi Australia

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MASC membership form - Annual 2013 - Maccabi Australia

MACCABI AMATEUR SWIMMING CLUB

MEMBERSHIP FORM

□ New Member □ Renewal Previous/Current Club _________________________

□ Transfer □ 2nd Claim SNSW Member # _____________________

First Name ____________________________ Surname _____________________________________

Date of Birth (dd/mm/yyyy) _________________________ Gender __________

Address _______________________________________________ Suburb _______________________

Postcode ________________

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.

Parent/Guardian Declaration

_____________________________

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

Parent Signature

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

(please tick)

□ 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

Please Note:

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 ____________________________

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