BERTS BRICKS ATLETIEKKLUB / ATHLETIC CLUB

Van / Surname:

LIDMAATSKAP 2017 / MEMBERSHIP 2017

Voorletters / Initials:

Noemnaam / First name:

Id no:

ALGEMENE INLIGTING: GENERAL INFORMATION:

Tydtoets: DinsdaeDrawwers: Somertye 18:00 Wintertye 17:30Stappers: Somertye 16:45 Wintertye 16:15

'n Klubfrokkie moet met registrasie aangekoopword

Time trials: TuesdaysRunners: Summer time 18:00 Wintertime 17:30Walkers: Summer time 16:45 Wintertime 16:15

A club vest must be purchased with registration

EK ONDERNEEM DIE VOLGENDE: 1 UNDERTAKE THE FOLLOWING:

Om onderheweig te wees aan klubreels. Om inklubkleure rooi frokkie met 'n donkerbloubroek

(navy) deel te neem

Om hulp te verleen by wedlope, tydtoetse enklubruns

Om aan ten minste 5 wedlope gedurende die jaardeel te neem

To comply by club rules. To take part in races inclub colours red vest with navy shorts

To assist with club races, time trials and club runs

To take part in at least 5 races during the year

EK IS BEREID OM OP EEN VAN DIE VOLGENDE WEDLOPE TE WERK /I SHALL WORK AT ONE OF THE FOLLOWING RACES:

Great Brickrun 21.1km

21/01/2017

BB 32km & 15km

06/05/2017

Supa Quick 10km

18/10/2017

MY KLUB AKTIWITEITE GEDURENDE 2016 / MY CLUB ACTIVITIES DURING 2016:

LYS 5 WEDLOPE / LIST 5 RACES

1) 2) 3)

4). 5).

Handtekening/ Signature: Datum / Date:

Vir Kantoorgebruik / For Office Use:

ASNW Fooie: R220.00 Klubfooie: R200.00 Klubfrokkie: R230.00 F / S

Totaal: Kwitansie no: ASNW no:

Banking details: Berts Bricks Atletiekklub ABSA Bank Tjekrekeningnommer: 1039460242

Takkode: 630005-Verwysing: Voorletters en Van / Reference: Initials and Surname

stuur na bertsbricksac@qmail.com Aandag: Zelma Olivier

2017 LICENCE FORM ASAThe completeness and accuracy of this submission, helps to improve Athletics South Africa's service to you.

Athlete

Track&Field

Coach

Cross Country

Tech Off

Road Running Race Walking

Your Details (Please tick where applicable)Surname Title (Mr/Ms/Dr etc)

First Name Initials

Type of Document ID Document n Birth Certificate Passport [ Refugee Permit

Licence Number (2015) Licence Number (2016)

Please enter the relevant number

ASA Province

Club Name (in full)

Gender: Female Date of Birth (YYYY-MM-DD)

Residential Address - Domicilium Rule Postal Address

Code Code

Tel Code Tel Number (Home) Tel Code Tel Number (Work)

Cell Phone Number

E-mail Address

Demographics

Black Coloured Indian White

Occupation

I declare that I am a bona fide athlete/coach/technical official. I confirm that all the information provided on this application is true andcorrect. I subject myself to the rules and regulations of Athletics South Africa and the IAAF, and I undertake not to compete in any trackevent, road race, cross country event, race walking event or fun run which is not sanctioned by the provincial athletics body and ASA.I indemnify ASA, the provincial body, sponsors and organisers of any race against all and any action of whatever nature which may ariseout of my participation and I agree that it is my responsibility to be medically fit to compete in any event.

Next of Kin: Name

Date....

Tel

Signature.,

Signature of Parent/Guardian (Younger than 18yrs) Signature..

Signature of Club Representative Signature-

Signature and stamp of the Province Signature

Welcome to the Athletics South Africa Family