Annual Membership Form                    (PDF)                          Season: 200___ to 200___

Contact Details                                  Please fill out all sections of this form so we can ensure your info is up-to-date.

Name

 

 

Names of Other Seniors or U19’s

 

 

Names of Junior Surf members

 

 

Physical address

 

 

Postal address

(if different to above)

 

 

e-Mail address

 

Home Phone

 

Work Phone

 

Mobile Phone

 

Privacy Act 1993

I do / don’t agree for the United North Piha Lifeguard Service Inc to use my contact details to send and receive information related to my membership.

Fees

Membership Type

Amount

No

Paid

Life Member

No Charge

 

 

Patrolling – Senior

$60.00

 

 

Patrolling – U19

$30.00

 

 

Associate *See Note 1

$30.00

 

 

JuniorSurf *See Note 2

1st Child

$25.00

 

 

                                                                     

2nd Child

$15.00

 

 

                                                                     

3rd & Subsequent Children

No Charge

 

 

Supporter

$50.00

 

 

Activity Fees

 

 

 

Senior Competition Levy  (covers SLSNR Events only)

$50.00

 

 

U19 Competition Levy  (covers SLSNR Events only)

$30.00

 

 

Senior/U19 Equipment Levy

$50.00

 

 

JuniorSurf A Group Equipment Levy – per child

$15.00

 

 

JuniorSurf B Group Equipment Levy – per child

$30.00

 

 

JuniorSurf C Group Equipment Levy – per child

$40.00

 

 

Donations

 

Discounts *See Note 3

 

PAID BY: CHEQUE/CASH/DC     DATE: ___ / ___ /___     RECEIPT: Y / N

Amount Paid

$

Notes

1.      Associate Members: Non-patrolling but taking an active role in coaching, admin or other aspects of the club operation (coaches, committee, parents of JuniorSurf members, spouse of patrollers etc) at the BOD’s discretion.

2.      Maximum Family Membership Fee: Excluding Competition and Equipment Levies the maximum membership fees payable by a family, residing at the same address is $120.00.

3.      Discounts: Members who complete 30 or more hours patrolling during the previous season are entitled to a discount off their membership fees, if paid by the 1st of December.  The discounts are $40.00 off Senior Fees and $20.00 off U19 Fees.

Membership Fees & Levies are due for payment by the 1st of October. Where fees have not been paid by the 1st of December then discounts will no longer be available and membership privileges will be withdrawn from those members until payment has been received.

·  PLEASE MAKE SURE WE’VE GOT ALL YOUR INFO.

·  Send completed form to the Secretary.

 

Fees can be paid by Direct Credit to our ASB account:

·  UNITED NORTH PIHA LIFEGUARD SERVICE INC

·  12-3075-0113089-000

Enter your name in the “Particulars” and “Reference” fields.