I am a: (Mark all activities relevant)
Discipline: (Mark relevant disciplines)
Demographics – SRSA Requirement
Identification Document Type:
Residential Address: – Domicillium Rule
EMAIL – Please enter your email, so we can follow up with you.
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
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]