UPPER BLUE MOUNTAINS BUSHWALKING CLUB INC - MEMBERSHIP 2017
PERSONAL DETAILS:
Full Name:
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No. & Street: ___________________________________________Suburb: ___________________________State: _________ Postcode: _________
Home Phone: ____________________________ Mobile: ____________________________________ Work Phone: _________________________
E-mail:
______________________________________________________ If no email provided, add $10 to your payment to receive the quarterly program by mail.
EMERGENCY CONTACT(S):
Name/s:
Please provide the details of someone we can contact in case of emergency.
______________________________________________________________
Phone/s: ______________________________________________
ACKNOWLEDGEMENT OF RISKS AND OBLIGATIONS OF MEMBERS:
This acknowledgement of risks applies to all Club activities I may undertake as a member of Upper Blue Mountains Bushwalking Club (the Club). In voluntarily participating in activities of the
Club which are described to me by the activity leaders I am aware that my participation in the activities may expose me to hazards and risks that could lead to injury, illness or death or to loss
of or damage to my property. Those risks may include but are not limited to slippery and/or uneven surfaces, rocks being dislodged, falling at edges of cliffs or drops or elsewhere, risks
associated with crossing creeks, hypothermia and heat exhaustion.
I also acknowledge that I may encounter weather conditions that could lead to hypothermia and being in locations where evacuation for medical treatment may take hours or days. In particular when participating in abseiling or above the snowline activities I am aware that these activities could expose me to additional hazards and risks described to me by the activity leader.
To minimise these risks I will endeavour to ensure (1) each activity is within my capabilities, and (2) I am carrying food, water and equipment appropriate for the activity, and (3) I will advise
the activity leader if I am taking any medication or have any physical or other limitation that might affect my participation in the activity, and (4) I will make every effort to remain with the rest of
the party during the activity, and (5) I will advise the leader of any concerns I am having, and (6) I will comply with all reasonable instructions of Club officers and the activity leader.
I have read and understand the above requirements; I have considered the risks before choosing to sign this acknowledgment of risk. I still wish to join the activities of the Club. I
acknowledge that I will take responsibility for my own actions and that signing this form and the payment of my subscription will be deemed as full acceptance and understanding of the above
conditions. I agree by signing this form to waive any claim for damages that I may have against the Club, the leader or other participants in tort or contract.
I also agree to be bound by the constitution of the Club for the time being in force.
Under 18?
YES / NO
Do you hold a Current First Aid Certificate?
YES / NO
If yes, date current to
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Full Name
Signature (or Guardian)
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Date
MEMBERSHIP FEES SCHEDULE:
Membership is normally for a calendar year.
Single Membership - $25 Family Membership - $45 (for first two members then $10 for each additional member - assumes all members live at the same address)
If applicable, add $10 to receive program by mail.
Total amount paid $_________
Paid by: □ Cheque/Money Order □ Direct Deposit
Please post this form with your cheque or money order payable to “UBMBC Inc”, PO Box 49, Blackheath 2785 OR pay by direct deposit to BSB No: 082656; Account No: 945613455
(NAB Katoomba NSW - UBMBC Inc). Please put your name in the payment reference. You will still need to post your completed form or scan and e-mail it to [email protected]