Members - Kempsey Crescent Head SLSC

Membership to our club is available all year round. If you would like to join as either an active or social member, please download and complete the attached membership form, or fill out the online form below.

Online Membership Form

If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

General Details

Title (Mr, Mrs, Ms, Etc).

First Name *

Second Initial

Last Name *

Post Nominal

Date of Birth *

Family Group Name

Occupation

Address (Please include suburb and postcode) *

Preferred Contact Phone Number *

Email *

Drivers License Number

Drivers License Type

Drivers License Expiry Date

Membership Details

Date Joined

Locker Number

Key Number

Membership Protection Number (where applicable)

Other Surf Life Saving Club Memberships?

Medical Details

If you suffer or you have suffered from any disease or any physical or mental disability (eg, epilepsy, diabetes or any permanent disability to a limb, eye or ear) likely to affect your efficiency as a Club member, it may affect your safety and the safety of the public. You should consult your medical practitioner and SLSA prior to commencing any surf lifesaving activity. You should take part in a Hepatitis B vaccination program.

Emergency Contact

First Name *

Last Name *

Relationship *

Address (Please include suburb and postcode) *

Emergency Contact Number *

Background

If You Chose Yes To The Above Question, What Background?

If You Chose Yes To The Above Question, What Language?

Declaration

I have read, understood, acknowledge and agree to the declaration and application and conditions of membership over leaf. I have signed that declaration and application. I warrant that all information provided is true and correct.

Signature (Please Type Name)

Parent/Legal Guardian Consent

(IN RESPECT TO AN APPLICANT UNDER THE AGE OF 18 YEARS)
I have read, understood, acknowledge and agree to the declaration and application and conditions of membership overleaf and I personally consent to the declaration and application for Membership of the applicant.

First Name

Last Name

Signature (Please Type Name)

Membership Declaration – please read before submitting membership form

Membership Declaration

Membership Fee’s

Social/Associate Member (non-active)	$40
Senior active members (all senior members over the age of 18)*	$40
Junior*	$25
Life Member	$00
Honorary Member	$00

*Any new src/bronze will have to pay a $50 additional cost

**General Members in surf guard are defined as members who are active within club activities however are not patrolling

To make payment please pay directly to :

Account Name: Kempsey Crescent Head SLSC Inc

BSB: 704-189

Account Number: 00005251

Please reference : Membership, Initial and Surname (ie Membership J.Smith)