Pro Rata - MPV Membership Form 2024/25

Membership Application Form Pro Rata - 2024/25
2024/2025 Membership Options and Fee Structure 1/10/2024 - 31/03/2025 Please select*

Family Membership (multiple athletes and parents) $75.00Senior Athlete (non PCV member) $50.00Student over 18( non PCV member) $37.50Student under 18 (including parental supporter)$57.50MPV- PCV Joint membership over 18 $25.00MPV-PCV Joint membership under 18 (including parental supporter)$45.00Non Athlete - Official or Supporter $20.00Life Membership - No fee required.
Remit you payments via DIRECT DEBIT to Modern Pentathlon Victoria

BSB: 633-000 ACC: 184-943-652

Email a copy or your payment receipt to modernpentathlonvic@gmail.com
Athlete Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Telephone
Family Membership

Additional family members details - Pentathletes
Name - Family Member 2
Birth Date

MonthDayYear
Name - Family Member 3
Birth Date

MonthDayYear
Name - Family Member 4
Birth Date

MonthDayYear
Adult Family Members / Officials / Parental Supporter for U18
Name - Adult 1
WWC - Working with Children Check
Telephone
E-mail
example@example.com
Name - Adult 2
WWC - Working with Children Check
Telephone
E-mail
example@example.com
Equipment Audit

Please provide details of all equipment owned or on loan.
Laser Pistol Model & Serial Number
Ownership Status
Target Make l & Serial Number
Ownership Status
Additional Equipment Register - Please include all hub equipment
Should be Empty:

Membership Application Form Pro Rata - 2024/25

Remit you payments via DIRECT DEBIT to Modern Pentathlon Victoria

Family Membership

Adult Family Members / Officials / Parental Supporter for U18

Equipment Audit