PAPANUI TOC H ATHLETIC CLUB Inc.

Track and Field Cross Country Road Masters Childrens Walking

REGISTRATION FORM 2012/2013

Athlete last name Age at 31-12-12 Total Fee (see reverse) Athlete first name M/F Date of Birth School Attending

Street Number SUBURB

STREET TOTAL PAID POST CODE Birth Certificate Sighted RECEIPT No.

Phone To be completed by

Mobile Phone

E-mail (please write clearly) To be completed by

PARENTS OF CHILDREN (5 to 14 years)

Fathers Name Mothers Name Mothers Name Parent Signature Parent Signature

SENIOR ATHLETES (15 years & over)

Athletes Signature

Do you give consent for your own/childs name and or image to be printed in any form in the clubs various publications? YES / NO

Tuesday nights (Club night)

I agree to help a minimum of 4 nights over the season. (I.e. supervise

younger children, time keep, long jump measuring etc). Your name and phone number will be added to our Parent Help Roster.

THE SUCCESS OF OUR CLUB IS DEPENDENT ON VOLUNTARY COMMITMENT

The information contained in this form will be only used by the Club and Athletics Canterbury
Subscription payments can be made by Direct Debit, the clubs bank account details are: Amount to pay: Bank: SBS Bank Account No: 031355 0558374 00 Account Name: Papanui Toc H Athletic Club Incorporated Payee Details: Members Names If payment is made by direct debit please include members name(s) for the clubs reference and email us at craig_shona@xtra.co.nz with the completed form when payment is made so we can record the payment details .

Alternative method of payment, payment by installment, is available. Please talk to the Registration Officer or club Treasurer if you wish to pay by this method.

CLUB SUBSCRIPTIONS AND REGISTRATION FEES. Club only Registered Senior/Masters $ 105 $ 165 Age as at 31/12/12 17, 18, 19 $ 95 $ 140 Age as at 31/12/12 15, 16 $ 95 $ 130 Age as at 31/12/12 - 12, 13, 14 $ 88 Age as at 31/12/12 - 7, 8, 9, 10, 11 $ 83 6 & Under $ 30 SocialNon Participating Members Only $ 30 Family Sub. 10% discount if 2 or more members of the same family living at the same address join. Only valid for Club subscriptions and registration fees. Club subscriptions include a $20 track maintenance levy.

Canterbury Children's Athletics

Saturday mornings only. In addition to club subs. One child/family $ 40 Two Children/family $ 65 More than two children/family $ 85 Club Family discount does not apply to these fees. Championship entry fees to be paid for each child registered for Saturday morning competition. Children 10 14 $ 8 Children 9 & under $ 6

Members registered for the Harrier season may have a reduced fee or nothing to pay. Check with the Registration Secretary about this. Fee Calculation Club Sub Less Discount Childrens Championship entry Total Member 1 _________ _________ _________ _________ _________ Member 2 _________ _________ _________ _________ _________ Member 3 _________ _________ _________ _________ _________ Member 4 _________ _________ _________ _________ _________