Membership Payment Form Step 1 of 5 20% Name* First Last Parents Name (If Junior) First Last Email* Address* Street Address Address Line 2 City/Suburb State Post Code Home PhoneMobile PhoneFax Email Ambulance Cover (Subscription/Health Care Card Number) Family Members*Riders NameAgeDate of BirthSenior / JuniorMV License NumberExpiry Click the plus on the right hand side to add another family member, click the minus to remove a memberDo you or anyone in your family hold a Level 2 First Aid Certificate Yes No Are you able to provide a Relative/Friend to help out on a Roster System for Canteen Duty on Major Racing Events? Yes No Are you willing to offer your help on Major Racing Events? Yes No In making an application for a club membership, I acknowledge & understand; I agree to be bound by the rules & regulations for the Korumburra Motorcycle Club Inc. This membership does not allow me to participate in competitive activity. This membership only permits me to participate in activities organised by the Korumburra Motorcycle Club until the end of the calendar year. This membership does not apply to another clubs activities unless stated on invitation formApplicants Signature*Parent/Guardian(If under 18 years of age) 15. EXECUTION I THE UNDERSIGNED STATE THAT I HAVE READ AND UNDERSTOOD THIS DECLARATION (INCLUDING THE WARNING, INDEMNITY AND RELEASE) AND AGREE TO THE TERMS AND CONDITIONS AS STATED. Name SignaturePassenger Signature16. THIRD PARTY INDEMNITY WHERE PARTICIPANT IS UNDER 18 YEARS OF AGEI/WE being the parents or guardians of the person named in Clause 1 (hereinafter called "the entrant") HEREBY ACKNOWLEDGE: a) I/we have read the whole of this document and understand it; b) I/we consent to the applicant becoming a member of MA and the relevant SCB and participating in Motorcycling Activities; AND c) I/we are aware of the risks, dangers and obligations set out in Clause 3 above; d) I/we acknowledge that the applicant is bound by and subject to the rules and policies of MA and the relevant SCB, including, without limitation, the MA anti-doping policy. 17. IN CONSIDERATION of the applicant being accepted as a member I/WE HEREBY INDEMNIFY AND RELEASE the Motorcycling Organisations in the same manner and to the same effect as if I/WE were the applicant and agree to personally accept all terms and conditions and obligations set out in this declaration.Parent/Guardian SignatureDate DD slash MM slash YYYY Passenger's Parent/Guardian SignatureDate DD slash MM slash YYYY Type* Renewel New Membership Membership Type* Full - Family Full - Single Full Membership runs from 1st Jan to 31st of DecemberTotal $ 0.00 Δ
