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CLARENCE MEMBERSHIP FORM

New member: Renewing member: - Member No. if known:
Activity:

1. MEMBERSHIP DETAILS
Date first joined:
Membership Type
Adult $20 Concession $15 Student/Child $15 Family $40

2. MEMBER DETAILS
Title: Mr / Mrs / Ms / Miss Last Name:
First name:
Sex: Male Female D.O.B. ../../.. Age: Yrs
Postal address:
Suburb: Postcode
Telephone: (H) (W) (M)
Email:
Emergency contact name:
Emergency contact no:

3. MEMBERS DECLARATION AND PAYMENT DETAILS (STAFF ONLY)
Total fees: $ Payment type:
cash / cheque / card
Receipt no:
Staff signature: Join date Expiry date Member no:

Date of renewal

Date of expiry Receipt no. Signature:
Date of renewal

Date of expiry Receipt no. Signature:
Date of renewal

Date of expiry Receipt no. Signature:
Date of renewal

Date of expiry Receipt no. Signature:

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4. MEMBERSHIP TERMS AND CONDITIONS
Suspensions: Club membership cannot be suspended, refunded or transferred without club superintendent approval.
Parental consent if under 18: All members under the age of 18yrs need the consent from a parent/guardian in order to use the
facilities.
Authorisation: All users of the Clarence PCYC must be authorised to use the facilities to the satisfaction of the Club
Superintendent
The unique philosophy of the club: I acknowledge and understand that the Clarence PCYC is a registered charitable not for profit
organisation. The club is largely self funded relying upon the income from club entries, memberships, community support, grants,
subsidies and assistance from Tasmania Police. I understand that the clubs primary objective is to IMPROVE COMMUNITIES
THROUGH YOUTH DEVELOPMENT. I acknowledge that my membership contributions enable the clubs youth outreach programs
to operate.
Medical information:- To your knowledge do you / your child have or have you / your child had any illnesses or injuries that may
prevent you / he / she from exercising or may increase the risk of injury whilst exercising? Yes / No
If you answered YES, please provide details............................................................................................................................................
RULES OF ENTRY:
Please ensure you have read and understood all the conditions of use prior to acknowledging them.
At all times, consideration for the comfort and safety of others is expected. Behaviour which offends, causes discomfort,
embarrassment, injury or damage to another user is unacceptable. If the Club Superintendent or another authorised officer
considers that a person has exhibited such behaviour, they can immediately terminate that persons use of the facilities and
require that person to vacate the premises.
ACKNOWLEDGEMENT OF RISK, INJURY AND OBLIGATIONS:
I acknowledge that the activity I am to undertake may be dangerous and that by participating in it I am exposed to certain risks. I
acknowledge and understand that whilst participating in such activity;
I may be injured, physically or mentally or may die
My personal property may be lost or damaged
Other persons participating in such activity may cause me injury or may damage my property
I may cause injury to other persons or damage their property
The conditions in which the activity is conducted may vary without warning
I may be injured or die or suffer damage to my property as a result of the negligence or breach of contract of Clarence PCYC
There may be no or inadequate facilities for treatment and transport of me if I am injured
I assume the risk and responsibility for any injury, death or property damage resulting from my participation in the activity
RELEASE AND INDEMNITY:
I participate in the activity at my sole risk and responsibility.
I release, indemnify and hold harmless Clarence PCYC its servants and agents, from and against all and any actions or claims which
may be made by me or on my behalf or by other parties for or in respect of arising out of injury, loss, damage or death caused to me
or my property whether by negligence, breach of contract or in any way whatsoever.
5. MEMBERS DECLARATION AND PAYMENT DETAILS
Before signing this document, I have read, understand and hereby agree to the terms and conditions of membership as defined on
the back of this membership form and know that it affects my legal rights. And I hereby certify that the information in this application
form is true and correct.
I agree to pay the following fees:

Total fees this membership: $..........................................................................

Signature:....

Parent/Guardian (if U/18yrs).... Date: ..//.