Student Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Consent if member is under 18years *

“I, the undersigned, approve of my son/daughter’s involvement in the activities of the Club. I accept full responsibility for my son/daughter and his/her belongings whilst taking part in such activity. I authorise the Officials of the Club, in the event of accident or illness, to obtain all necessary medical assistance and treatment, including blood transfusions and anesthetic and I agree to pay all such fees and expenses incurred. I also agree that the Officials/Leaders should be free of any responsibility for any accident or illness incurred during my son/daughter’s involvement in activities at the various centres and venues or whilst training or playing competitive sport.”

I Agree

If member is over 18years

“I, the undersigned hereby apply for membership of the Hawthorn Citizens’ Youth Club Incorporated, and agree to be bound by the Rules of the Club for the time being in force. I accept full responsibility for my involvement in my chosen activity and for my belongings whilst taking part in such activity. I authorise the Officials of the Club, in the event of accident or illness, to obtain all necessary medical assistance and treatment, including blood transfusions and anesthetic and I agree to pay all such fees and expenses incurred. I also agree that the Officials/Leaders should be free of any responsibility for any accident or illness incurred during my involvement in activities at the various centres and venues or whilst training or playing competitive sport.”

I Agree