HEDLAND SHARKS  APPLICATION FOR NEW / RENEWAL MEMBERSHIP FORM

  SEASON.

HEDLAND AMATEUR SWIMMING CLUB INC,  PO Box 351 Port Hedland WA 6721                 ABN: 198 77078 473 

NEW SWIMMERS PLEASE COMPLETE FORM AND BRING ALONG BIRTH CERTIFICATE.

1. SWIMMERS  SURNAME:   and  GIVEN NAME:

2.   D O B                   SEX:     M F                 AGE:

If you were a financial member for 2005 – 2006 season and none of the information required below has

changed please go to item 9.

Parent/Guardian Name:

Phone:(hm)    (wk)        Mob  

Physical Address:  

P.O. Box    Email: 

    3.   Were you registered with a different club last season?     Yes No
    4.   If yes, please state Name of Club:

    5.   Do you suffer from any Medical Conditions? Asthma, epilepsy etc…                  Yes No

    6.   If yes, please provide details:  (Please fill in EMERGENCY CONTACT INFO)

    7.   Will you give permission for the Club to publish photographs of 
          your family members on the Club Website / picture gallery.   Yes No  

    8.   Do you wish to receive Club correspondence through Email   Yes No   

    9.   If your Family owns / operates a business would you consider sponsoring HASC?  Yes No     

  10.   I, the undersigned, hereby apply for membership on behalf of  

 to the Hedland Amateur Swimming Club Inc. under the terms and conditions as presented in the current rules.

Please note that your child cannot participate in any Club activities until financial.

Registrar………………………………