Registration and Membership Form 2025

Registration and Membership form 2025

Please complete form
Minor child details:*

First NameSurname
Photo of minor child

Photo of minor child
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Minor child date of birth (D.O.B.) *

DayMonthYear
Please indicate sporting code/s
Copy of birth certificate

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T-shirt size*
Pants size*
Parents/ Legal Guardian/s details

Details of parent/Legal Guardian/s
Mother or Legal Guardian of minor child*

PrefixFirst NameLast Name
Email address
example@example.com
Phone Number
Please enter a valid phone number.
Father / Mother / Legal Guardian

PrefixFirst NameMiddle NameLast Name
Email address
example@example.com
Phone Number
Please enter a valid phone number.
Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical information of minor child

Complete the form carefully
Medical Emergency Contact Name and Surname:*

First NameSurname
Medical emergency contact number
Please enter a valid phone number.
Does your child have any medical conditions i.e. chronic illness or allergies? Specify yes or no:*
Yes/No
Describe medical condition and or Allergies:
Describe medical condition and or allergies
Is your child on any chronic medication? Please specify Yes/No:*
Yes/No
Specify chronic medication
Chronic medication
Does your child have medical aid? Yes/No :
Yes/No
Medical Aid - Main member name and surname:

First NameSurname
Medical aid name
medical aid name
Medical aid plan name
medical aid plan name
Medical aid number
medical aid number
TERMS and CONDITIONS

Please read and accept terms and conditions
EXEMPTION and LIABILITY

Please read and accept exemption and liability below : I, the Parent/ Legal guardian/s, whos name/s and surname/s appears herein, hereby exempt Les Guerriers Youth Development and Empowerment Academy NPC and any of their members from liability for any injuries, fatalities, or loss of personal belongings that may occur during my minor child's participation in any activities. I understand that this exemption includes, but is not limited to, any claims for damages or expenses that may arise from: - Personal injuries or fatalities - Loss or damage to personal belongings - Any other incident or accident that may occur during any activities. I acknowledge that I have read and understood this exemption and indemnity clause and agree to its terms and conditions.
DECLARATION FORM

Please complete declaration form
Declaration by Parent/s or Legal Guardian personal information confirmation

Please read the declaration set out below and agree to the personal information provided in the completed form. I Mother / Father / Legal guardian/s whose name appears herein agree and confirm that the personal information completed in this registration and membership form are true and correct and completed to the best of my knowledge as the parent / legal guardian. I / we hereby declare that my child, whos name appears herein, is fit and able to participate in the specified sporting code/s indicated in this form - I indemnify Les Guerriers Youth Development Empowerment Academy NPC, its Directors, officials, any of its members, employees, and agents, against any liabilities, medical fatalities, injuries, or incidents that may occur as a result of my child's participation. - I understand that it is my responsibility to ensure that my child is properly supervised and cared for during any activities. *Consent:* - I grant permission for my child to participate in the specified sporting code/s as per the form completed herein. - I understand that photographs and/or videos may be taken during any activities related for this purpose, and I consent to the use for promotional purposes.
REGISTRATION and MEMBERSHIP FEES APPLICABLE :

Registration fee = R50

Membership subscription valid for six(6) months = R150

Total Fee of R200 applicable upon registration.

NB
- Registration fee of R50 is a once off payment and Membership fee of R150 is ONLY valid for a period up to six(6)) months from date of receipt of payment received.
- See banking details below for confirmation
Name and Surname of person responsible for payment*

First NameSurname
Please indicate Cash or EFT payment:*
Indicate cash or EFT preference
LES GUERRIERS YOUTH DEVELOPMENT EMPOWERMENT ACADEMY NPC

BANKING DETAILS:

Bank name: FNB Business Account

Account type : Cheque

Acc no : 63153693700

Branch name : Paarl

Branch code : 200110

NB!

Please use payment ref no : Minor child's initial/s and surname

Please email receipt of payment to the following email address: lgacademy23@gmail.com
Signature of parent / Legal Guardian ............................................ Date*

MonthDayYear
Date
Should be Empty:

Parents/ Legal Guardian/s details

Medical information of minor child

TERMS and CONDITIONS

EXEMPTION and LIABILITY

DECLARATION FORM

Declaration by Parent/s or Legal Guardian personal information confirmation