THOSE IN BOLD ARE MANDATORY.

NAME:  _______________________(first)    ___________________________(last)
ADDRESS:  _________________________(Street/Box)   __________________(city)
TELEPHONE (home):  ___________________   Mobile:  __________________
TELEPHONE (work):  ____________________    Email:  _____________________________
MEMBERSHIP STATUS:   Senior Male   Senior Female   Student    Junior   Supporter   Family (circle one)
DATE OF BIRTH:  _______(day)   ____________(month)   ____________(year)
AWARDS HELD & DATE GAINED:  _________________________________________
PREVIOUS CLUB/S:  ______________________________________________________

STUDENTS AND JUNIORS ONLY
MEDICAL HISTORY/ALLERGIES:  ___________________________________________
EMERGENCY DETAILS:
______________________(name)  _______________________ (address) ____________(phone)

If elected, I agree to abide by the Constitution and rules of the Pacific Surf Life Saving Club.

Signed:……………………………………………….. Date: ………………………………………

Approved by Management Committee: ……………………………………………………………

SUBSCRIPTIONS TO BE PAID BY 31 OCTOBER, 2002
Senior Male:         $55.00 ($45 if paid by 15 October)
Senior Female:      $55.00 ($45 if paid by 15 October)
Supporter:             $20.00
Junior (under 14):  $15.00
Student:                $35.00 ($30 if paid by 15 October)
Family:                 $80.00 ($70 if paid by 15 October)