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Membership Form 0910 by ashrafp

VIEWS: 15 PAGES: 2

									                                             SWIMMING NSW Ltd

                                   MEMBERSHIP FORM

CLUB: __________________________ YEAR: _________________                      Please Circle: WINTER / SUMMER
 Renewal  New Member                Upgrade         Transfer: Previous Club ____________ (If applicable)

PERSONAL INFORMATION (*compulsory information)

Title Mr/Master/Miss/Ms/Mrs/Other: (Please specify) ______________________

First Name* _______________ Middle Name or Initial _____________ Last Name* __________________

Date of Birth* (dd/mm/yyyy )____________ Australian Citizen* Yes No

ID Number*___________ Swimmer with a Disability* (If applicable) Classification No. _______________


CONTACT INFORMATION (the privacy information and declaration overleaf must be signed)

Address*

Suburb* _____________              State* ______________               Postcode*

Telephone*: (Please tick preferred number, at least 1 number must be provided)

 Home (___)                                             Work (       )

 Mobile _________________________________

    PLEASE SUPPLY A VALID EMAIL ADDRESS – email will be the primary form of communication
  between members and Swimming NSW, therefore it is important these details are accurate , correct
                                  and checked regularly

Email Address*

I would like to receive via email:           Swimming NSW Streamline Newsletter
                                             Swimming NSW Swimmer Magazine Online
                                             Swimming Australia E-Swimmer

EMERGENCY CONTACT INFORMATION

First Name*_________________ Last Name* _________________Relationship*

Telephone* at least 1 number must be provided: Home (                ) __________________

Work (     )                            Mobile _______________________
                                                               Please continue on next page

Please note: Swimming NSW Ltd collects membership information in accordance with the Swimming Australia Ltd
Privacy Policy. Information on this and other policies is available at www.nswswimming.com.au
                                              SWIMMING NSW Ltd


                          MEMBERSHIP FORM (cont’d)

MEMBERSHIP DETAILS (only 1 must be selected).

        Swimmer                     Non-Swimmer                         Life Member
Note: A swimmer is defined as someone who swims at Club, Area, State or National level.
A non-swimmer is defined as someone who does not swims at any of these levels.

OTHER INFORMATION
 Coach              Official             Administrator             Learn-to-Swim (Swimmer or Instructor)

 Asthmatic          Non-English Speaking Background                    Indigenous 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 Protection and Privacy Policies (these are available at www.swimming.org.au ).

2. I authorise Swimming NSW 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, photograph and results published in official programs, newsletters and websites.



Signature (Member): ___________________________________                         Date: _______________


If Under 18 Name of Parent/Guardian: ___________________________________


Signature (Parent/Guardian): _____________________________                      Date: _______________

Other Information Required by Club:




Please note: Swimming NSW Ltd collects membership information in accordance with the Swimming Australia Ltd
Privacy Policy. Information on this and other policies is available at www.nswswimming.com.au
com.au

								
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