PAPANUI TOC H ATHLETIC CLUB Inc.
Track and Field Cross Country Road Walking Masters Childrens
REGISTRATION FORM 1/4/2016 – 31/3/2017
1. As a parent of a junior athlete I accept that I will be required to assist with Tuesday Club Nights at least four evenings. Interclub families volunteer at least four Saturday Interclub Competitions.
2. Parents/caregivers of under 7 children MUST be present with their children during club night.
3. I authorise for my own/child’s name, image to be used to promote Papanui Toc H and its activities.
4. I have read and agree to the Athletics New Zealand Membership Declaration provided below.
5. I agree to abide by the rules and constitution of the Papanui Toc H Athletic Club Inc.
6. I understand that: The Health and Safety Act applies to all participants, spectators and volunteers of events run by Papanui Toc H.
7. I understand that: I may be subjected to Police Vetting, particularly if working with Junior members.
In signing this form I understand my obligation to the club and accept the above.
Signed: Name: Date:_________
Contact Details To be clearly filled in by parent/guardian or Senior Athlete 15 years & over
Parent/Guardian Names Email Mobile/Landline
Father Mother
Street No. Street Suburb Post Code
Athlete First & Last name M
F
Date of Birth
Age at
31/12/16 School Attending Total Fee
Club Membership - Age as at 31/12/15 Members registered for the Harrier season may have a reduced fee or nothing to pay. Check with the Registration Secretary.
15+ Years 14 Years & younger 7-14 Years Coaching
Social (Club only)
Registered (Club & Interclub)
Social (Club only)
Competitive
(Interclub Fee) Thursday Night Training
Senior / Masters $93 $135 $88
One child family $50 $60
18, 19 years $93 $120 $83
Two children family $75 $40
15, 16, 17 years $93 $112.50 2016 Harriers (Winter) $0 More than two children $100
Full Season (Oct – March) First Half (Oct – Dec)
Social Fee + Interclub Fee = CCAA Registered (ie. Saturday Athletics)
Payment Payments can be made by Direct Debit Payment by instalment is available
Bank: SBS Bank
Account No: 031355 0558374 00
Account Name: Papanui Toc H Athletic Club Incorporated Payee Details: Member Names
Please email completed form with payment to: [email protected]
Club Use Only Receipt No.
Payment Cash Rego fee Coaching Total $ to pay
Internet Cheque Credit Card PayPal How did you hear about Papanui
Toc H?
Facebook Web Flyer School Friend Family
Birth Certificate Sighted Y / N
6 years & under 7, 8, 9, 10 years 11, 12, 13, 14 years
$30
Athletics New Zealand Membership Declaration
I, being the applicant or the applicant’s parent/guardian, agree to the following.
1. Accuracy: The details I have provided are true and correct. If any details change I agree to notify Athletics NZ of the changes as soon as possible after they occur. If any details provided are not correct (or are misleading) I acknowledge this application for membership may be declined (or if already accepted, terminated) at the discretion of Athletics NZ.
2. Rules: I agree to be bound by the Athletics NZ Constitution and any other rules, regulations, guidelines, codes of conduct, or reasonable directions of Athletics NZ including the Athletics NZ Anti-Doping Regulations and by the IAAF Anti-Doping Rules and Regulations.
3. Acceptance of Risk: I have voluntarily accepted and assumed the inherent risk of danger and injury in being involved in Athletics.
4. No Liability: I will not hold Athletics NZ (or their officers, employees, or agents) responsible for any claims, losses or expenses which may arise from or in connection with my membership or my participation in any activity authorised or recognised by Athletics NZ or held at a location controlled by Athletics NZ (except in the case of gross negligence).
5. Indemnity: I indemnify Athletics NZ from all claims, losses and expenses suffered or incurred as a result of my failure to observe the Athletics NZ Constitution or any other rules, regulations, guidelines, or reasonable directions of Athletics NZ.
6. Medical Declaration: I am medically and physically fit. I do not suffer from any injury, illness, or condition (physical or mental) that would affect my ability to safely participate in Athletics and other related activities with Athletics NZ. I have completed this form accurately to record any matters that Athletics NZ needs to be aware of with regard to my health.
7. Privacy: I agree that Athletics NZ can collect, hold, use, and disclose any personal information (including any photos of me) obtained through this form or as a result of my membership for the following purposes:
a. processing my application for membership and providing services to me;
b. compiling and maintaining a database of members of Athletics NZ;
c. including my name and contact details on contact lists for use by Athletics NZ staff and officials;
d. requesting me to renew if my membership lapses;
e. publishing photos of me and details about my involvement in any Athletics events, competitions, or activities in Athletics NZ publications (such as websites and newsletters);
f. selecting and publicly naming competitors and teams to represent Athletics NZ;
g. providing me with information about Athletics NZ;
h. enabling Athletics NZ to contact me with information about the products and services of supporters, sponsors, funders and other organisations with a relationship with Athletics NZ (unless I opt out of receiving such information on this form);
i. enabling Athletics NZ to comply with any applicable statutes, regulations, bylaws and other regulatory instruments;
j. retaining the information provided on this form if my membership lapses (as an inactive member) for a maximum period of three years for the above purposes; and
k. any other purpose I agree to with Athletics NZ.
8. Access & Correction: I understand that I have the right to access (and correct) any personal information held by Athletics NZ as provided for in the Privacy Act.
9. Continued Membership: I understand that upon payment of my membership fee(s), if this application is accepted by Athletics NZ, I will become a member of Athletics NZ, and continue to be a member until either: my membership expires, I resign, I fail to pay any fees due, or my membership is terminated by Athletics NZ.
10. Interpretation: Every reference to “I” and “my” in this document includes the applicant and the parent/guardian of the applicant (if applicable). Every reference to “Athletics NZ” means Athletics New Zealand Incorporated.