Membership Application
Please fill out details below
Please fill out your details to apply for membership.
You can also download our application form and send it in.
PERSONAL DETAILS
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First and Last Name*
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Date of Birth
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Address
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Are you a breast cancer survivor or supporter (all welcome)*
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Can you swim 100 metres without a flotation device?*
It is a legal requirement you wear a PFD (personal flotation device) in the winter months. ASA will supply unless you have your own.
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CONTACT DETAILS
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Mobile Number*
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Email Address*
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Work Phone Number
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Home Phone Number
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EMERGENCY CONTACT DETAILS
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Name*
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Relationship*
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Mobile Number*
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Work/Home Number
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AGREEMENTS & DISCLAIMER
Please select the membership you wish to join and read and agree to abide by our constitution and review our disclaimer
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Membership Type I Am Applying For*
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Declaration*
I agree to abide by the Constitution of Adelaide Survivors Abreast Inc Dragon Boat Club. I will not hold the Club or any of its members personal injury or loss of property suffered by me at Club activities whether or not the same be due to the Club, its servants or agents.
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