Name

First Name

Last Name

Date of birth

Please note: MM/DD/YYYY

YYYY

Mobile Phone Number

Home Phone Number

Please assist us be providing a regularly checked email address. Most club correspondence will be sent in this manner.

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

Name & Phone Number Must be different to contacts above

Details of any relevant medical conditions, including severity & medication

If you use asthma medication or an epipen, please email us a copy of your current action plan. If there are no medical conditions, please write N/A

Vaccination Status

Covid-19 Vaccination is mandatory for all 12+. Proof of vaccination will be required prior to entry to the gym.

Fully Vaccinated

Exempt

Partially Vaccinated

Medicare Number

Ambulance Cover

Yes

Private Hospital Cover

How did you hear about Eastern Gymnastics Club?

Returning Member

Family member attends club

Gymnastics Party

Club Website

Gymnastics Australia/Victoria Website

Social Media

Referral from existing member (please specify below)

Other (please specify below)

Notes to Eastern

Any further notes or information needed for your enrolment?

Please advise the Club, in writing, of any changes to your enrolment, in accordance with the rules of the Club.

DECLARATION

I, the undersigned, approve this application for membership and in doing so, agree that Eastern Gymnastics Club Incorporated and/or its representatives (the Club) be free and clear of any responsibility for any accident or illness during the applicant’s participation in any activity concerned with this enrolment to the extent permitted by law. I further authorise the Club to obtain any medical assistance as is required and agree to meet any expense attached thereto. I declare that the applicant has been in good health and agree to advise immediately in the event of his or her contracting any ailment likely to be detrimental to the health of others or sustaining any relevant injury. I also agree to abide by the rules and policies as set by the club, which are available on request from the office, or on our website.

CONSENT TO USE PHOTOGRAPHS AND VIDEO FOOTAGE

From time to time Eastern Gymnastics Club may photograph or video current gymnasts for training purposes, or to use these images in Club publications and promotions and through on-line marketing or social media. If images are used we will avoid, where possible, naming or identifying the gymnast. I give permission for my image to be used: • For training purposes • In EGC publications and promotions (e.g. newsletters, website, print media, signage) • On social media (including but not limited to Facebook, Instagram, YouTube and Twitter)

DO YOU CONSENT?

Yes

BY CLICKING SUBMIT YOU APPROVE OF ALL OF THE ABOVE

Thank you for your time, please email us at enquires@easterngymnastics.com.au with any questions!

2022 ADULT GYMNAST MEMBERSHIP FORM

Please complete the form below