SDRQ Membership form - Sled Dog Racing Queensland
Transcription
SDRQ Membership form - Sled Dog Racing Queensland
Return to Club Secretary PO Box 1445 Capalaba 4157 [email protected] Sled Dog Racing Queensland Inc. Membership Application Form CHOOSE APPROPRIATE OPTION: Membership renewal New member I/We the undersigned of (Name and residential address) __________________________________________________________________________________ __________________________________________________________________________________ Email: ________________________________________ Mobile: ____________________________ MEMBERSHIP OPTIONS: New Single Membership (includes club safety kit) $80 New Family (2 Parents and Children up to 18) / Couples Membership $125 (includes club safety kit, additional safety kit option for $45 at time of joining) Single annual membership renewal fee $45 Family annual membership renewal fee $80 Members’ Safety Kit $60 Club Shirt (S,M,L,XL) $TBA Size: ______________ PERSONAL INFORMATION: Emergency Contact: ______________________________ Relationship to member:______________ Phone:___________________________________ Mobile: __________________________________ Please provide details of any medical conditions: (and details of emergency treatments e.g. location of Epipen/medications)______________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ________________________________________________________________________________ As a Member/s of Sled Dog Racing Queensland Inc. I/we Agree to: • Supply copies of all dogs’ current vaccination certificates, and provide copies of future certificates when boosters occur. • Abide by the Incorporation Rules, Club Rules and Code of Conduct of Sled Dog Racing Queensland Inc. • Act as reputable members of SDRQ Inc. by upholding the code of conduct and objectives of the club • Allow Sled Dog Racing Queensland Inc. to use photo and footage of the members named on this form for promotional material (newsletters, printed or web based) SDRQ Inc Updated 9 April 2015 Membership Includes: • A Starter Information Pack • A copy of the Incorporation & Club rules and Code of Conduct Policy • Branded Safety Kit • Insurance coverage for Sled dog Racing Queensland Inc. events • Discounted race entry fees PAYMENT INFORMATION: Payment can be made by Cash, Cheque or EFT transfer. Account name: Sled Dog Racing Queensland Inc. BSB: 302 162 Account: 075604 1 I/We enclose $ ______________________ being for the payment of Membership Fees/ Club shirt. Signature/s (over 16yrs): ____________________________________________________________ Parent/Guardian Signature (Under 16yrs): ______________________________________________ Name and address of Parent/Guardian: ________________________________________________ Membership includes ASSA membership and insurance. However in the event of a claim please note there is a $2500 excess fee that will be at the claimant’s expense. How did you hear about us? _______________________________________________________________________________ Have you raced dogs before? Where? Skill Level? _______________________________________________________________________________ Is there anything you may be able to assist SDRQ Inc. with? Details of your dogs: Dog Name Age /Sex Breed Vaccination Cert. Sighted OFFICE USE ONLY Amount Paid: __________________ Date Paid: ________________________ Paid by (Circle one): CASH CHEQUE EFT TRANSFER Receipt Number: ________________ Member Number: _____________ Musher starter kit received: YES / NO Nominated By: _________________________________ Seconded By: _________________________________ SDRQ Inc Updated 9 April 2015