MEMBERSHIP RENEWAL FORM

General Information

First Name:  *
Last Name:  *
Date of Birth:  calendar
Suburb:  *
Mobile:  *
Email:  *
 Current Working with Children Check

Payment: SUA 063118 | 10101629 | Ref: Your Name

 $100 Senior Membership 18+
 $60 Junior Membership U/18
Polo Shirt Size: 
Please advise of any medical conditions, injury or safety concerns : 
Please accurately complete the above as failure to disclose accurate information may preclude the payment of any compensation.

Emergency Contact Information

Contact name: 
Relationship: 
Mobile: 
Any further information that may assist in the case of an emergency?: 
 I accept all appointments made by coaches and agree to be bound by the rules and constitution of the Southern Umpires Association. I agree to maintain accurate details in Schedula and register myself on FootyWeb *
 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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