MEMBERSHIP RENEWAL FORM

General Information

Member number: 
First Name:  *
Last Name:  *
Address (Number and Street):  *
Suburb:  *
Postcode:  *
Home phone:  *
Mobile:  *
Personal email:  *
Please advise of any change in circumstances, including medical conditions: 
The accurate completion of the above section is crucial, failure to disclose any accurate or misleading information may preclude the payment of any compensation in the event of any injury or death.

Emergency Contact Information

Contact name: 
Relationship: 
Contact home phone: 
Contact mobile phone: 
Is there any further information that may assist in the case of an emergency?: 
 I shall accept all appointments made by the Southern Umpires Association coaches and agree to be bound by the rules, contract, and constitution of the Southern Umpires Association, for the period of my appointment (a copy can be viewed in the SUA Kananook Office on request). I agree to update my personal details including Working With Children Check, umpiring information and umpire match day availability on Schedula (www.schedula.org.au). I agree to register myself on FootyWeb: the National Umpire Registration Database and keep my details up to date at all times (link to FootyWeb is on the SUA website) *
 I give permission for images of myself to be used on any website or social media that is controlled by the Southern Umpires Association, and accept that this image may be used in any publication thereafter. *
 I am the parent/guardian of the above named, who is under 18 years of age. As the parent/guardian I am afforded the rights of Social Membership of the SUA. I have read this document, and consent to its terms and conditions for both the applicant and myself as a Social Member.
Name of parent/guardian: 
 

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