- Member
- Discipline
- Emergency
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Applicant's Contact Details
First Name
Last Name
Contact Number
Date of Birth
ID Number
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Residential Address
Street Number & Road Name
Suburb
Post Code
Town
Country
List Your Discipline Criteria
Primary Discipline
Indicate Discipline
Affiliations
CSA ID (Lic No)
ROAG ID (Lic No)
Skill & Fitness Based On Universal (UCI / IMBA) Ratings
Skill Level Rating
Fitness Level Rating
Annual Registration Fee Plan
Select Plan Option
Emergency Contact Details
Primary Emergency Contact Name
Primary Emergency Contact Number
Secondary Emergency Contact Name
Secondary Emergency Contact Number
Alternative Emergency Contact Name
Alternative Emergency Contact Name
Medical Aid Detail
Medical Aid Name
Medical Aid Plan
Medical Aid Number
Medical Aid Primary Member Name
Medications | Allergies | Blood Type
Please list any allergies
Please list any medication you may be on or in case of emergencies
Blood Type
Club Affiliation Prospects
Please provide name of KPCC member who can vouch for you.
Terms & Conditions
I understand: 1. That my online application form must be submitted online and will be reviewed by the committee for acceptance. 2. That the Executive committee has the right to refuse any application for membership without assigning any reasons for such refusal. 3. That the membership fee shall accompany my application upon committee agreement and confirmation of acceptance is communicated to myself. If my application is not accepted, such fee shall be returned to me. 4. Upon acceptance, I shall get myself familiar with the club’s constitution which can be found on the website www.kingsparkcycling.co.za. I hereby indemnify the KINGS PARK CYCLING CLUB and hold it harmless against all claims for damages to property and all claims arising from death of, or injury to, any person whomsoever, or damage to equipment to vehicles whether partaking or otherwise involved in, in any activity or in any cycling event organised or authorised by the Kings Park Cycling Club. Persons selecting the below check box of this online indemnity form as guardian of a minor hereby consent to such minor being bound by the foregoing & further indemnify any parties, if any, to which such a minor is not capable of waiving his/her rights as stipulated above.
I agree to the Terms and Conditions
Please check the highlighted fields.