Powerchair Sports Victoria Membership Form

REGISTRATION FOR POWERCHAIR SPORTS VICTORIA

Please complete this form to become a General Member of POWERCHAIR SPORTS VICTORIA

· General Membership is $14.00 Adults/$6.00 Under 16's including a $2.00 joining fee for new members. These fees help PSV cover insurance costs.

· Volunteer General Memberships are free.

· Playing fees are $120.00 per season.

· Organisation Memberships are $35.00

If you have any questions, please email luke.david@psv.org.au

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* 1. Applicant's contact details

First Name

Surname

Address

Surburb

State

Postal Code

Contact number

Organisation

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* 2. Email address

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* 3. Date of birth

Date / Time

Date

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* 4. Membership category

General Member

Volunteer

Playing Fees

Organisation Membership

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* 5. Name of disability (players only)

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* 6. Parent, advocate or emergency contact information

First Name

Surname

Relationship

Contact Number

City/Town

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* 7. By filling out this registration form, I also give consent to the publication of written information pertaining to me (excluding medical or health information) and to the publication of my personal image and performance results, for non-commercial educational, promotional and archival purposes for the sports.

Agree

Disagree

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* 1. Applicant's contact details

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* 2. Email address

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* 3. Date of birth

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* 4. Membership category

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* 5. Name of disability (﻿players only)

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* 6. Parent, advocate or emergency contact information

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* 5. Name of disability (players only)