2015-16 Membership Form

Date of issue: April 2015
Membership Form
2015-16
Please note: This form MUST be submitted to your club for approval prior to sending
to Athletics Victoria. Submissions of AV forms offline includes a $10 processing fee.
Your Details
Athletics Victoria ABN 47 382 664 821 When completed and signed this form constitutes a tax invoice.
*mandatory fields
*Athletics Club
*Family Name
*Given Name(s)
*
*AddressPostcode
Street Address/PO Box
Suburb/Town
Home No.
First time registered
* Mobile No.
notifications
required
for SMS
*Email
required for email notifications and member newsletter
*Gender
Male
Work No.
*Date of Birth (DD/MM/YYYY)
Female
Yes No
/
/
No Disability Classification (if applicable)
Disability Yes
LAVic Centre
Name of Coach
Little Athletics Victoria Centre (if applicable)
Emergency Contact
*Name
*Contact No.
*Signed by Member or Guardian
Relationship to Member
In signing this form, I agree to the terms and conditions of
membership of Athletics Victoria Inc as well as the Declaration
overleaf and have included payment for Athletics Victoria Inc. fees. Date
*Signed by Club Registrar
DD / MM / YYYY Date DD / MM / YYYY
Membership Fees (please tick; see over page for details)
A.Athlete$170
Open
Youth
$75
LAVic
(see over for details)
$150
Under 18/20 (as at 31/12/15)
Dual
$55
LAVic
(see over for details)
$130
Under 14/16 (as at 31/12/15)
Social
$40 Recreational Runner
Official
$0 (Membership form required for registration)
Coach
$0
B. Additional Fees
Alternate First Claim +$40
+$40
Second Claim
C. Discounts
$60
(current accredited coach with Athletics Australia)
Additional Fees and Discounts (please tick; see over page for details)
Club Name
x
CR
T&F
(Tick appropriate season)
Country Athlete
Family
Alternate First or Second Claim:
(not applicable to Youth & Dual)
(3 or more Athlete family members and
not applicable to Youth & Dual)
-$20
-$15
per athlete
Total Membership Cost
A. $ + B.
$
- C.
Athletics Victoria membership fees can be
paid by cash or credit card.
Please complete and submit this form to your
club for approval.
Office Use Only
Date Processed:
Total 2015-16 AV Membership Fee $
$
CREDIT CARD PAYMENT (MASTERCARD & VISA ONLY):
Cardholder Name:
Member Number:
Cardholder Signature:
15-16 Bib Number:
Expiry:
/
Processed By:
cvv:
Membership 2015-16
JOIN.EXPERIENCE.BENEFIT
JOIN – As a member – competing athlete, official, coach, affiliate, club, as a commercial partner, a
government, any stakeholder partnership.
EXPERIENCE – Our events/competitions, educational courses/seminars, athlete development, sponsor
activation, our consultation services.
BENEFIT -Overall health & wellbeing, individual and team performance/results, personal &
professional development, knowledge gain, social integration and community relationships, club
awareness & member return and team identity.
MEMBERSHIP ACCESS
•Access to a well-organised and structured series
of events in your particular area of interest.
•Expert coaching and guidance through our club
network.
•Personal accident & insurance coverage.
•Exclusive discounts & training access to Lakeside
Stadium.
•Member offers and discounts
•AV Member Card
•Summer and Winter Handbooks (digital)
•Access to Championships (fee based)
•Access Target Talent Program (age restrictions)
•Access to State Teams (age restrictions)
•Discounted fees (Dual, Youth, Country Athlete &
Families)
•Customer Service
•$50 timing Chip (free with AV membership &
XCR entry for new members and XCR entrants)
•Year-round professionally run events
•athsvicTV
•Results archive
• Online registration (one payment for club and
AV)
•Insurance
• Free entry to AV Shield rounds
• Race bib
• Member and Clubs portal access
• Online entry
• Discounted entry to various events
• Monthly E-Newsletter
• Lakeside Stadium access
ATHLETICS VICTORIA LEVEL 1, 31 AUGHTIE DRIVE, ALBERT PARK VIC 3206
PH: (03) 8646 4500
FAX: (03) 8646 4544
Terms & Conditions
1. By completing this application and submitting payment you acknowledge
the terms and conditions of AV’s membership.
2. This document relates to any person applying for membership with
Athletics Victoria Inc. for the period 1/4/2015 to 31/3/2016. This
registration is valid only for the nominated season and does not carry over
into the next athletics year. Refunds will be determined as per Athletics
Victoria’s refund policy. No other exceptions will be made.
3. In the following terms and conditions, the term ‘AV’ refers to Athletics Victoria Inc.
The term ‘XCR’15’ refers to all competition between 1/4/2015 and
30/9/2015, and the term ‘Track & Field season’ refers to all competition between
1/10/2015 and 31/3/2016.
4. I hereby make application for membership of AV with the club/specialist
group listed and declare that I am eligible to participate in competition
according to the eligibility laws set down by the By Laws of Athletics Victoria. I
agree to abide by all the Rules and By Laws of AV, Memorandums, Articles
and By Laws of Athletics Australia and Constitution and Rules of the
International Association of Athletics Federation and any subsequent
amendments.
5. If the applicant is under 18 years-of-age, the parent/guardian is
responsible for the applicant and the applicant’s compliance to rules of
membership.
6. I understand that at an AV event or related activities, I may be
photographed and/or videotaped by an official or endorsed representative
of AV. I acknowledge and agree that any images or likeness captured by AV
are owned by AV and that they may be used by AV for promotional or other
purposes without my further consent being necessary. Further, I hereby
consent to AV using my name, image, likeness and also my performance in
any AV/AA events, at any time, by any form of media, to promote the event
and AV/AA. AV is not responsible for those images or likenesses captured
by persons who are not an official or endorsed representative of AV.
7. I understand that these rules are subject to change at AV’s discretion, and
that a current copy of all rules, regulations and policies can be obtained
from the AV office and also the AV website at www.athsvic.org.au.
8. Final approval of your membership is conditional upon your club
providing endorsement. Membership is not complete until this process is
finalised.
9. DAMAGED OR LOST PROPERTY: I agree to provide payment for any fees
associated with AV damaged or lost property. I understand that failure to do
so may result in disqualification from competitions.
10. REGISTRATION TYPES:
ATHLETE – An athlete is allowed to compete at AV events according to the
various rules and policies relating to all AV competitions. Athlete
classifications for fee purposes are: UNDER 14/16 ATHLETE – for people
born 1/1/2000 to 31/3/2011; UNDER 18/20 ATHLETE – for people
born 1/1/1996 to 31/12/1999; OPEN – all other athletes.
DUAL & YOUTH ATHLETES (11-17 years) – Dual Athletes are those athletes
aged between 11 and 14 years (as at 31/12/2015) who are current
members of Little Athletics Victoria (LAVic). Youth athletes are those aged
between 15 and 17 years (as at 31/12/2015) who have been members
of LAVic at any stage since 1/1/2013. LAVic Athletes must nominate a
LAVic Centre on this form in order to be eligible for this membership, and in
claiming this membership type, no other discount may be claimed. If you are
not eligible for this category additional costs may be incurred.
SOCIAL – Social members are non-competing members who contribute to
the sport in ways other than listed above.
RECREATIONAL RUNNER – Recreational running members must be
registered with an affiliated Athletics Victoria specialist group or the Victorian
Running Network (VRN).
OFFICIAL – AV welcomes the registration of persons who are prepared to
officiate at athletic events conducted by AV. To act as an official, AV requires
persons to undertake a Working with Children Check (as a volunteer there is no
cost for this check). AV will facilitate training to assist officials to increase their skill
levels and become accredited under the national accreditation scheme.
COACH – Victorian based coaches must register via Athletics Australia’s
Coach Accreditation scheme, this includes registration with Athletics Victoria.
For further information and to register online as a coach visit http://www.
athletics.com.au/coaches.
ALTERNATE FIRST CLAIM – Alternate First Claim registration enables an athlete
to nominate a club, other than their home club, to compete for in either the
XCR’15 or Track & Field season. This registration is valid only for the
nominated season and does not carry over into the next athletics year.
Alternate first claim registration must be completed by 1/6/2015 for the
XCR’15 season, or 1/12/2015 for the Track & Field season.
SECOND CLAIM – Athletes who compete first claim for a club that does not
participate in AV Shield competition are eligible to nominate a second claim
club for the Track & Field season. Second claim registration permits the athlete
to compete with their second claim club in any competition in which their first
claim club is not competing. Applications for second claim membership must be
completed by 1/12/2015. Athletes who have nominated an alternate first
claim for XCR season cannot second claim for the track and field season.
TRANSFER – Any member that was registered with an AV club at any time in
the period 1/4/2013 to 31/3/2015, who is applying to register with a
different club, is required to complete a transfer and submit a completed
transfer form. This form requires written clearance from the applicant’s present
club and must accompany the application. Applications for a transfer of
membership to compete for a club must be completed by 1/6/2015 for
XCR’15 season or 1/12/2015 for Track & Field season. Any person who
has been refused a clearance by a club, or whose application for a
clearance has not been dealt with within 21 days of lodging their
application, may lodge an appeal with the AV Board. The letter of refusal of
clearance by the club concerned, or evidence that the application was made
to the club 21 days prior to the lodgment of the claim must accompany any
such appeal.
11. DISCOUNTS:
COUNTRY: This discount applies to those members registering with an
affiliated AV Country club. It does not apply to country residents registering
with an affiliated AV Metro club.
FAMILY DISCOUNT – This discount applies if three or more members of the
same family, residing at the same address, register at the same time. Those
registering as Officials, Coaches, Social, Recreational Runners or Dual & Youth
Athletes are not eligible for the family discount.
12. I understand that my membership details are collected by AV for the
purpose of conducting and creating my membership permitting me to enter
Events conducted by AV including but not limited to identifying participants in
an Event, recording results, communicating with me and other participants
about Events and to assist AV in improving and marketing its goods and
services. I understand that by supplying AV with my e-mail address I wish to
receive regular e-newsletter updates from AV in order to stay informed about
Events conducted by AV.
13. I understand that my personal information is being collected by AV in
compliance with the regulations set out in the Privacy Act 1988, as
amended(“Privacy Act”), and the Australian Privacy Principles for the purpose of
conducting and facilitating my membership of Athletics Victoria. I understand
that if I choose not to share certain personal information that my membership
application may be rejected at AV’s discretion. I understand that if I wish, I am
able to access, change and update information AV has about me at any time
by contacting AV, subject to the terms of the Privacy Act. I understand that AV
will endeavour to respond to my request within 30 days, that AV may be
contacted during normal working hours on (03) 8646 4500 and that AV is
happy to send to me a full copy of the Privacy Policy should I require more
information. I acknowledge that the Privacy Policy also contains information
about how I may complain about how my personal information is handled,
used and disclosed. I agree to the sharing of my personal information with AV
and its insurers in relation to any incident or personal illness that has reasonable
and direct relation to my membership and/or any event that I enter.
14. In addition to the matters in condition 13, by applying for membership of
AV I consent to my personal information being provided to Athletics Australia
Limited for the purposes of registering me on a national database controlled by
Athletics Australia. I further consent to receiving information (including via email)
from Athletics Australia, including details of other events and specials offers or
promotions, unless I inform those organisations otherwise.
By ticking this box I declare I have read and understand the terms and conditions above.
Declaration
Athletics Victoria Inc. (AV) has a duty of care to its members and to the general public who interact with its employees, volunteers, members and others involved
with AV activities. As part of this duty of care and as a requirement of AV’s Member Protection Policy, AV must enquire into the background of those applying
for, undertaking or remaining in any work (paid or voluntary) that involves working with people under the age of 18 years. At AV’s discretion, we may require
any member over the age of 18 to undertake a Working with Children Check. Therefore, we require all members to confirm the declaration below:
‘I do not have any criminal convictions or findings of guilt for offences involving sexual activity, act of indecency, child abuse or child pornography.’
‘I do not have any criminal charge pending before the courts. I have not had any disciplinary proceedings brought against me by an employer, sporting
organisation or similar body involving child abuse, sexual misconduct or harassment, acts of violence, intimidation or other forms of harassment.’
By ticking this box I declare I agree to the above statements and comply with AV’s requirements for involvement in AV activities.
ATHLETICS VICTORIA LEVEL 1, 31 AUGHTIE DRIVE, ALBERT PARK VIC 3206
PH: (03) 8646 4500
FAX: (03) 8646 4544