APPLICATION FOR MEMBERSHIP FOR 2016
I wish to apply for membership of Capital GymSports (“Club”) located at 11 Hutchison Road, PO Box 7555, Newtown and in so doing also apply for membership of GymSports NZ Incorporated located at Level 2, 6 Arawa Street, Grafton, Auckland.
This form has been prepared to ensure compliance with the Privacy Act 1993 and the Incorporated Societies Act 1908. Please complete all spaces on the form for each person applying for membership. Failure to complete all spaces may result in refusal to accept membership. For more information refer to the GymSports NZ Membership Data Regulation. If the gymnast is under 18 years, the parent/guardian/caregiver should complete this form for the gymnast as detailed below.
1.	CLASS DETAILS 
CLASS	
     	
DAY/s OF WEEK	
     	
TIME	
     	

2. PERIOD OF MEMBERSHIP 
PERIOD    	
    click on box and select Full year (1 Jan to 31 Dec 2016), or term(s) that apply from the list.	

Indicating full year/term refers to the membership details on this form and is required for the Privacy Act. Payment of fees is separate and based on the club’s policy. A new form will be required on completion of the indicated period. 	
3. GYMNAST DETAILS
GIVEN NAME	
     	
SURNAME	
     	

DATE OF BIRTH	
     	
GENDER	
         click on box and select	

ADDRESS	
     	

SUBURB	
     	
TOWN / CITY	
     	
POST CODE	
    	

PHONE (Home)	
     	
PHONE (Work)	
     	
MOBILE	
     	

(PRE) SCHOOL	
     	

EMAIL	
     	

ETHNICITY 	
    click on box and select 	
OTHER – details:	
     	

At least one contact phone number must be supplied.	
4. EMERGENCY CONTACTS 
Provide at least one emergency contact. If the member is under 18 list their parent/guardians and one additional contact. 
NAME	
     	
RELATIONSHIP	
     	

PHONE (Home)	
     	
PHONE (Work)	
     	
MOBILE	
     	

NAME	
     	
RELATIONSHIP	
     	

PHONE (Home)	
     	
PHONE (Work)	
     	
MOBILE	
     	

NAME	
     	
RELATIONSHIP	
     	

PHONE (Home)	
     	
PHONE (Work)	
     	
MOBILE	
     	

5. MEDICAL CONDITIONS: 
List any medical conditions that may impact on the gymnast participating in Gymsports (eg epilepsy, asthma, allergies etc). Please read paragraph 6 (overleaf). 
     

In the unlikely event of an injury or illness occurring while the gymnast is participating in Gymsports, the Club or GymSports NZ (as applicable) will make every effort to contact the emergency contact listed above as soon as possible. By signing this form you authorise the Club to administer such first aid as it considers necessary. 	
6. INFORMATION FROM SPONSORS 
I agree that GymSports NZ or my Club may contact me from time to time to provide me with information about the products and services of my Club or GymSports NZ sponsors or funders.
I AGREE	
  click on box and select Yes or No	

Please note that membership is not confirmed until fees are paid as per the Club’s policy and consent is given for the membership declaration overleaf. 

MEMBERSHIP DECLARATION 
1. Accuracy: The details set out in this Membership Form are true and correct. If they change I acknowledge that I am required to notify my Club of the changes in writing as soon as possible after they occur. If the details provided are not true or are misleading I acknowledge my membership may be terminated at the discretion of my Club and GymSports NZ. 
2. Bound by Rules: I will be bound by the constitutions, regulations, policies, manuals, guidelines and reasonable directions of my Club, and GymSports NZ. 
3. Accept Risk of Gymsports: I have voluntarily accepted and assumed the inherent risk of danger and injury in Gymsports. 
4. No liability: I will not hold my Club or GymSports NZ or their respective officers responsible or any claims, losses and expenses and costs (including legal costs) which may arise from or in connection with my membership and/or participation in any activity authorised or recognised by my Club or GymSports NZ except in the case of gross negligence or a wilful act or omission on the part of my Club or GymSports NZ. 
5. Indemnity: I indemnify my Club and GymSports NZ from all claims, losses and expenses (including legal costs) suffered or incurred at any time as a result of, or resulting directly or indirectly from, my failure to observe the constitutions, regulations, policies, manuals, guidelines and reasonable directions of my Club and GymSports NZ respectively. 
6. Medical Declaration: I am medically and physically fit and do not suffer from any injury, disease or condition, either physical or mental, that would affect my ability to safely participate in any authorised or recognised activities of my Club or GymSports NZ. If I am unsure about this declaration, or suffer from such a condition I have either listed it on this form or I am aware that I must bring it to the attention of my Club and GymSports NZ. 
7. Privacy: I agree that my Club and GymSports NZ can collect, hold, use and disclose my personal information as provided on this Form (and any updated or additional personal information the Club or GymSports NZ obtains from me including any photo or other record of my image) for the purposes of: 
a. Processing my application for membership including notifying the Club and GymSports NZ of the information on this form for the purposes of the Club and GymSports NZ compiling a register of members, compiling a national database of members and participants (accessible only in accordance with the Constitution and Regulations of GymSports NZ), and for requesting me to renew if my membership lapses; 
b. Putting my name and contact information on my Club’s membership list for use by other members of my Club; 
c. Publishing any of my Gymsports results in my Club and/or GymSports NZ’s newsletters and on their websites; 
d. Selecting and publicly naming competitors and teams to represent my Club and GymSports NZ at Gymsports events; 
e. Providing me with information and activities relating to my Club and GymSports NZ and other Gymsports matters; 
f. Including my photograph or other imagery on the Club and/or GymSports NZ website, in newsletters, annual reports, or similar official publications; 
g. Enabling my Club and GymSports NZ to contact me with information about the products and services of Club or GymSports NZ sponsors or funders (unless I have opted out of receiving such information on the Membership Form); 
h. Enabling my Club and GymSports NZ to comply with any statute, regulation, by-law or other regulatory instrument that requires collection or disclosure of personal information; 
i. Retaining the information provided on this form if my membership lapses (as an inactive member) for a maximum period of three years for the above purposes; and 
j. Any other purpose I agree to in writing. 
8. Use, Security and Access: I understand that my personal information will only be used for the purposes listed in paragraph 7 and in accordance with the GymSports NZ Regulations, and that: 
a. My personal information will be held securely; 
b. I will have access to my personal information under the Privacy Act; 
c. My personal information will be corrected upon request. 
9. Continued Membership: I understand that upon payment of my membership fee(s), if I am accepted to membership, I will become a member of my Club and GymSports NZ and that by paying such fee(s) by the due date(s), I will continue to be a member of my Club and GymSports NZ for the duration of my Membership as specified on this form and in accordance with the GymSports NZ Constitution, unless I resign or my membership is terminated. 
10. Interpretation: Every reference to “I” and “my” in this document includes the gymnast and the parent/guardian/caregiver of the gymnast (if applicable). 
Copies of constitutions, regulations, policies, manuals and guidelines of the Club and GymSports NZ can be obtained by contacting your Club or GymSports NZ via www.gymsportsnz.com.

DECLARATION 	For members 18 years and over 
I have read and consent to the Membership Declaration.
I CONSENT	  click on box and select Yes or No	DATE	     	

DECLARATION 	Parent/guardian/caregiver consent for members under 18 years: 
I am the parent/guardian/caregiver of the gymnast who is under 18 years of age. I have read and understood this form and the Membership Declaration. I consent to the gymnast’s application for membership on the basis set out in this form and the Membership Declaration. 
I also consent, or am authorised to consent, to the emergency contact details specified in this form being held by the Club and GymSports NZ for the purposes of contacting the person(s) named in an emergency. 
If I am not a member myself, I also consent to my name and contact details as set out below, being collected, held, and used as the gymnast’s parent, guardian or caregiver in accordance with the purposes set out in paragraph 7 of the Membership Declaration as if I were a member of GymSports NZ. 
GIVEN NAME	     	SURNAME	     	
I CONSENT	  click on box and select Yes or No	DATE	     	
EMAIL	     	
PHONE (Home)	     	PHONE (Work)	     	MOBILE	     	
At least one contact phone number must be supplied.