Please enable JavaScript in your browser to complete this form.Title *Title (Mr/Ms/Dr/Etc.)NAME *First NameInitials *InitialsSURNAME *SurnameI am a: *AthleteCoachTechnical OfficerI am a: (Mark all activities relevant)Discipline *Track & FieldOff-Road RunningRoad RunningRace WalkDiscipline: (Mark relevant disciplines)Demographics *BlackColouredIndianWhiteOtherDemographics – SRSA RequirementAge CategorySeniorJuniorHigh SchoolPrimary SchoolGender *MaleFemaleGenderD.O.B *Identity *ID Book / CardBirth CertificatePassportRefugee PermitIdentification Document Type:ID Number *Identification Document Number: BC Number, Passport Number, Refugee Permit NumberASA 2020 – Leave blank if new memberASA_2021 – leave blank if unknownPhysical Address *Address Line 1CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryResidential Address: – Domicillium Rule Telephone – Mobile/Cell *Mobile/CellTelephone – HomeTelephone – HomeTelephone HomeTelephone HomeEmail *EmailConfirm EmailEMAIL – Please enter your email, so we can follow up with you.Occupation – *Occupation -SRSA RequirementSurname of Next of Kin: *Surname of Next of Kin:Title *Title – [Mr, Mrs, Ms] Name of Next of Kin: *Name of Next of Kin:Initials *Initials Relationship *Telephone Mobile/Cell *mobileTelephone HomeHomeTelephone WorkWorkBy 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.DateDD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SIGNATURE *BY APPENDING YOUR NAME YOU DECLARE THAT THE CONTENTS ARE CORRECTYounger than 18 yearsFirstLastDate & Signature of Parent: (Younger than 18 years)Membership Application Form 2021 *Renewal of MembershipNew MembershipDate JoinedAnnual Fees 2021 *R100 Renewal for 2021 OnlyR150 for New Member 2021 OnlyPayment Method *EFT [Bank Transfer] Only – Due to covid-19 My Previous Running ExperienceMy aims/goals in joining the ClubI am willing to assist the Club in the following ways: Please tickGroup Leader/ CoachClub Socials & EventsClub AdminOtherPromotions *yesnoDO YOU WANT TO RECEIVE PROMOTIONAL MATERIAL FROM THE CLUB AND RACE SPONSORS?Medical aid name and PlanMedical Aid NumberPrincipal Membermed – conditionsMedical Conditions [Asthma, Heart Disease etc]Chronic MedicationCheckboxesFirst ChoiceSecond ChoiceThird ChoiceMessageSubmit