Title (Mr/Ms/Dr/Etc.)
First Name
Initials
Surname
I am a: (Mark all activities relevant)
Discipline: (Mark relevant disciplines)
Demographics – SRSA Requirement
Gender


Identification Document Type:

Identification Document Number:

2019 ASA Licence Number:
2020 ASA Licence Number:

Residential Address: – Domicillium Rule


Telephone Home
Telephone Work
Cellular Phone Number
EMAIL – Please enter your email, so we can follow up with you.
Occupation
Surname of Next of Kin:
Title – [Mr, Mrs, Ms]
Name of Next of Kin:
Initials
Home
Work
mobile
By signing this form, I hereby declare that the above information given is true and correct. I further declare and agree: • To abide by the constitution** of Brimstone – Itheko Sport Athletic Club • To abide by the rules and regulations of ASA ***(Athletics South Africa) and WPA (Western Province Athletics) • To indemnify Brimstone – Itheko Sport Athletic Club, its coaches, officers and assistants against all and any action of whatever nature for any loss, damage, illness or injuries that may be sustained or arise out of my participation in any training session, race or social event • That it is my responsibility to ensure that I am medically fit to train and compete in any race • To at all times behave in such a manner so as not to bring the name of Brimstone – Itheko Sport Athletic Club into disrepute • To at all times inform Brimstone – Itheko Sport Athletic Club of any change in medical conditions and any other relevant information

Declaration

I declare that I am a bona fide athlete/coach/technical official/office bearer. I confirm that all the information provided on this application is true and correct. I understand that my participation in an athletics related event is subject to the ASA Constitution, its rules and regulations. I understand that this licence can be retracted should I violate the ASA Constitution, its rules and regulations. I hereby accept that I participate in any event of ASA and its members entirely at my own risk. I indemnify ASA and its members, sponsors and organisers of any event against all and any action of whatever nature which may arise out of my participation and I agree that it is my responsibility to be medically fit to compete in any event. I understand that my information may be shared with ASA partners, in accordance with the ASA Privacy Policy. I understand that if I am a minor, my parent and/or legal guardian understands the nature of the athletic activity, approves of the declaration above, and signs it on my behalf.

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BY APPENDING YOUR NAME YOU DECLARE THAT THE CONTENTS ARE CORRECT
Date & Signature of Parent: (Younger than 18 years)
DO YOU WANT TO RECEIVE PROMOTIONAL MATERIAL FROM THE CLUB AND RACE SPONSORS?
Medical Conditions [Asthma, Heart Disease etc]