Day Membership Form

Day Membership Form

Register for a day membership and provide your contact and emergency details.
Membership Type (Fees are per day)
Date

DayMonthYear
Date
Show/Practice Venue
Name
Address Line 1
Address Line 2
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Amount Paid
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 - Day 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 Practice Day, Clinic or Competition.
Media Release Agreement

I {q5_textbox3} of {q6_textbox4} {q7_textbox5} 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
Please verify that you are human
Participant's Name

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

First NameLast Name
E-Signature
OFFICE USE ONLY - Payment Date

MonthDayYear
Date
Should be Empty: