Monash-Ski-and-board-membership-Online

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					                                                                                       Membership No: Online




First Name: Click here to enter text. Last Name/s: Click here to enter text.       D.O.B: Click here to enter text.
Membership type:
Monash Student ☐            Student ID: Click here to enter text.         Campus: Click here to enter text.
Monash Alumni ☐             Non-Monash Student         ☐        Non-Student ☐


Are you interested in:      Watersports ☐              Snowsports ☐               Both ☐

If you’re interested in being involved in the club’s committee, please tick the box ☐


Contact Details:
Phone No Click here to enter text.
Email Address: Click here to enter text. (Please ensure this is one you check all year around)
In case of emergency contact
Name: Click here to enter text. Relationship: Click here to enter text. Phone No: Click here to enter text.
Medical Details
Medicare No Click here to enter text. Expiry: Click here to enter text. Number on card: Click here to enter text.
Ambulance number: Click here to enter text.
Private health insurance (if applicable): Company: Click here to enter text. Number: Click here to enter text.

- Do you suffer from any of the following?
☐ Asthma                   ☐ Low Blood Pressure                 ☐ Heart Disease
☐ Diabetes                 ☐ High Blood Pressure                ☐ Epilepsy
☐ Allergies       - Please specify: Click here to enter text.
☐ Other           - Please specify: Click here to enter text.

Dietary Requirement
Vegetarian ☐                Other ☐      - Please Specify: Click here to enter text.

Declaration of Indemnity
I hereby declare that I will indemnify the Club, its committee of management and public officer as well as officers and
staff of MONSU Caulfield, MONSU Peninsula and Monash Pty. Ltd. in respect of any liability for claims, demands, actions
or proceedings whatsoever made or taken against them, arising out of loss or damage to property or personal injury as a
consequence of my acts or omissions whilst a member of this association. In signing up for Monash Ski and Board I
accept I receive proxy membership to all associated Victorian university snow and water clubs, in taking part of any
activity run by them I am accepting their membership terms.

Privacy Statement:
The information on this form is collected for the primary purpose of processing your application for membership. Other
purposes of collection include ensuring your safety in the event of an accident or emergency, attending to administrative
matters and corresponding with you. If you choose not to complete all the questions on this form, it may not be possible
for MONSU Caulfield or the club to process your membership. Personal information may also be disclosed to emergency
services or health professionals in the event of an emergency or accident. You have the right to access personal
information that Monash holds about you, subject to any exceptions in relevant legislation. If you wish to seek access to
your personal information or inquire about the handling of your personal information, please contact the Monash Privacy
Officer on 9903 2596.

I Accept the above membership conditions: ☐                         Date 30 March 2013

				
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