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Membership Form

Please complete in Block Letters


BASIC INFORMATION
Name:

___________________________________________________

Address:

________________________________________________

Surname

First

Other Names

________________________________________________
Email:

________________________

Phone:

_______________

_______________

Home

Cell

Date of Birth: _________________________ Age this year: ____________


Day

Religion:

Month

Year

________________________________________________

Parent / Guardian: _______________________________________________


Surname

First

Contact:

______________________________________________

Next of Kin:

______________________________________________

Contact:

______________________________________________

Work

Home

Surname

Mobile

First

Work

Home

Mobile

Emergency Contact: __________________________________ Tel: _____


Surname

First

_________________________________
Relationship to Member

For Sports, For Culture, For Community, For Christ!

Sport interest(s):
[ ] Aerobics
[ ] Karate
[ ] Track

[ ] Basketball
[ ] Cricket
[ ] Football
[ ] Netball
[ ] Swimming
[ ] Tennis
[ ] Other_______________________________________

Culture interest(s):
[ ] Chorale

[ ] Other_______________________________________

Community interest(s):
[ ] Volunteering
[ ] Homework Club
[ ] Book reading club
[ ] Other_______________________________________
Christ interest(s):
[ ] Outreach

[ ] Other_______________________________________

For Sports, For Culture, For Community, For Christ!

MEDICAL HISTORY
Please state any medical conditions and/or allergies that we should be aware of:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Please provide details of medication that must be administered:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Please state any past or current injuries that we should be aware of:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Family Doctor:

______________________________________________

Telephone No:

_____________________________________________

For Sports, For Culture, For Community, For Christ!

DECLARATION AND SIGNATURE


I hereby certify that the information that I have provided is accurate. I
understand that the 4 All Sports Club will not be held liable for any medical
claim if the information is submitted on the Medical Form is not accurate. I
have read the bye laws and agree to the terms of membership of the 4 All
Sports Club.
Signed _______________________ (Applicant)
(If the applicant is under 18 years this agreement must be signed by the parent, guardian or
other responsible person over 18 years. In signing below the parent, guardian or other
responsible person approves all the applicants obligations stated herein and constitutes a
guarantee of the applicants obligations also agreeing to further terms and conditions listed
below.)
1. I agree to my son/ daughter taking part in the activities of the club.
2. I confirm to the best of my knowledge that my son/ daughter does not
suffer from any medical condition other than those listed above.
3. I consent to my son/ daughter travelling by any form of public
transport, minibus or motor vehicle driven by a club coach or any other
parent attending, to any event in which the club is participating.
4. I understand that the Club or Organizers accept no responsibility for
loss, damage or injury caused by or during attendance on any of the
clubs organized activities except where such loss, damage or injury can
be shown to result directly from the negligence of the Club or the
Organizers.
Signed _______________________ (Parent/ Guardian)
Date __________________

For Sports, For Culture, For Community, For Christ!