Membership Application - Hartbeespoort Marathon Club

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2024 ASA PERMANENT LICENCE APPLICATION FORM

A license number will only be issued to the club, by the province, when this form is fully and correctly completed by the applicant, verified by the club, and accompanied by payment in full. The club/province may use an electronic registration system, with the form electronically signed and EFT payment made, provided the electronic system is aligned with the ASA license registration application system.

Please select *Existing memberNew member

I am a *AthleteSocial

Discipline *Track & FieldRoad RunningOff-Road RunningRace WalkingMark all relevant activities

Demographics - SRSA Requirement *AfricanColouredIndianWhite

Age category - SRSA Requirement *Senior+JuniorHigh SchoolPrimary School

Gender *MaleFemale

Date of Birth *

Title *(Mr/Ms/Dr/ect.)

Initials *

First Name *

Surname *

Type of Identification Document *ID Book/CardBirth CertificatePassportRefugee Permit

Number *

ASA Province: North West North 2022 License Number: NWN 2023 License Number: NWN Club Name (in full): Hartbeespoort Marathon Club

Residential Address - Domicilium Rule *0 / 180

Postal Address - Domicilium Rule *0 / 180

Code *

Tel/Cell phone number *1st

Tel/Cell phone number *2nd

Email Address *

Occupation

Next of Kin: Name *

Next of Kin: Phone *

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, approve of the declaration above, and sign it on my behalf.

08/09/2024

Name & Surname of Parent/Guardian (Younger than 18yrs)

Office use:

Club: I confirm that the above information is correct; the athlete is registered to no other club; and domicile is correct.

Date: .......................................... Signature of Club Representative: ..................................................................

Province: I confirm that the club is affilliated to the province; and the domicile of the club and application is correct.
Date: .......................................... Signature and stamp of the Province: ...........................................................

About Hartbeespoort Marathon Club

The HMC was Established on 4 September 1984 to fulfill the need of the Hartbeespoort community for an athletic club.

Although road running is still the main focus of the club, the club aspires to becoming a multi-sport club also encouraging its members to participate in other disciplines such as walking, cycling, swimming and trail running.

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