LVTC New Membership Application Form
For the period of 1st July 2011 to 30th June 2012. REG NO. 14209Y
SECTION 1: Member Details
TITLE:____SURNAME: _________________________ FIRSTNAME:_____________________
DATE OF BIRTH: ______________________ GENDER: M / F
ADDRESS:___________________________________________________________________
TOWN: ____________________________________________ POST CODE:_____________
PHONE: (H) ______________________ (M)____________________
EMAIL: ___________________________________________
OCCUPATION: _______________________________
Have you completed in a triathlon before? Yes / No
If “Yes”, over what distance (please circle)? Fun, Sprint, Olympic, ½ Ironman or Ironman
Are you currently a member of Triathlon Victoria? Yes / No. Tri Vic No.________________
SECTION 2: LVTC Membership for club only events (please tick)
[ ] Junior (U20) $15.00
[ ] Senior (20+) $30.00
[ ] Associate Member (Not Racing) $15.00
[ ] Family (2 Adults & 2 or more Children) $75.00
OR: Triathlon Victoria Membership and LVTC Membership (please tick)
[ ] Junior (U20) $105.00 + $15.00
[ ] Senior (20+) $147.00+$30.00
Send Membership form to P.O Box 1734 Traralgon 3844 or email to:
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Payment Options:
Direct deposit: BSB 803 140 A/c 14007878 or send cheque to: P.O Box 1734 Traralgon 3844
SECTION 3:
I, (full name) _______________________________ hereby apply to become a member of the LATROBE VALLEY TRIATHLON CLUB Inc. In the event of my admission as a member, I agree to be bound by the rules of the club as set down by the members and within the constitution.
Your email address could be used as part of the LVTC newsletter mail list.
Your name, address and phone number could be used in the newsletter club member contact list.
Please indicate that you authorise the LVTC to use your contact details in this way, Yes / No
Signature:_________________________ (member/parent/guardian) Date:____________
Joining Triathlon Victoria
I hereby make application for a Triathlon Race Licence for the period 1st July 2011 to 30th June 2012 and agree to abide by the rules and regulations of the sport. I understand that the information provided by me will be included in a Triathlon Australia national database and may be required for disclosure on occasions to the Australian Sports Commission, the Australian Institute of Sport, other Academies of Sport and the Australian Drug Agency. The information is not to be released to any commercial enterprise, excepting the sponsors of Triathlon Victoria may use my name and address to post promotional material to me. Information such as name, age, results and the like may be released to race directors and the media in response to general requests.
[ ] Please tick this box if you do not wish to receive any promotional information from the sponsors of Triathlon Victoria
Signature: __________________________(member/parent/guardian) Date:____________