Australian Extreme Obstacle Racing Yearly Membership

Australian Extreme Obstacle Racing Membership/Registration

Complete this registration form based on the club’s membership structure. Fields marked required must be completed. Provide any optional details only if applicable.
Applicant Details
First name
Surname
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Postal Address if different from above
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Age
D.O.B (Jnr, Young rider & Masters only)

MonthDayYear
Date
Emergency and Bank Details
Emergency Contact Name

First NameLast Name
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Bank Details - BSB
Bank Details - Account Number
Bank Details - Account Name
Membership and Rider Information
Rider Level
Membership Type
Media Release Agreement
I First Name Last Name of Street Address Address Line 2 City State Zip hereby grant permission for Australian Extreme Obstacle Racing Association Incorporated or its agents and assign all rights, to use my photo, video or recordings for the purpose of promotion of Australian Extreme Obstacle Racing for all forms of media for the following but not limited to news releases, photographs, video, live feeds and website marketing.
I agree that these images, videos or voice recordings may be used for a variety of
purposes and that these images may be used without further notifying me.
I acknowledge that I will not be compensated for the use of my images, videos and
voice recordings and that Australian Extreme Obstacle Racing Association Incorporated owns the rights to the images, videos and recordings.
I hereby release Australian Extreme Obstacle Racing Association Incorporated and its agents from any claims that may arise from these uses, including without limitation, claims of defamation or invasion of privacy, infringement of moral rights, rights of publicity or copyright.
Agreement
Membership Fees

Please forward receipt of payment to
admin@australianextremeobstacleracing.com.au
Australian Extreme Obstacle Racing Association Incorporated
BSB: 112-879 Account Number: 460 142 835
Use Reference eg: A Citizen - membership
ABN: 75 447 325 281

Risk Waiver - please read and sign the Risk Waiver form available on our website and email a copy or print and bring along to your first Practice Day, Clinic or Competition.
Participant's Name

First NameLast Name
Parent/Guardian's Name (required if under 18)

First NameLast Name
E-Signature
Date

MonthDayYear
Date
Please verify that you are human
Should be Empty:

Australian Extreme Obstacle Racing Membership/Registration

Applicant Details

Emergency and Bank Details

Membership and Rider Information