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Rupavahini Muthuhara 2514
Melbourne
Together Building A Better World
5/151, Greensborough Road, Macleod, VIC 3085
Tel.0409 568 547
Email: [email protected]
__________________________________________________________________________________________
All participants need to complete a Membership Form. This is strictly between the age group of
9-18.
MEMBER PERSONAL DETAILS
Member’s Full Name:
Gender:
Age:
Date of Birth:
School Year:
Nationality:
__________________________________________________________________________________
PARENT/GUARDIAN DETAILS
Parent’s/ Guardian’s Name:
Relationship to the child:
Address:
Home Phone:
Parent/Guardian Mobile:
Email:
Emergency contact names & numbers
Name of the Person:
Number:
_________________________________________________________________________________
MEDICAL DETAILS
Doctor’s Name:
Address:
Telephone Number:
Does your child have any medical condition?
Yes/No
If yes, please give details:
Does your child have Ambulance Coverage
Yes/No
If yes, please provide the Ambulance number:
__________________________________________________________________________________
Member’s Talents & Skills
1. Do you speak Sinhala?
Yes/No
2. How would you like to rate your knowledge of Sinhalese?
Speaking
Reading
Writing
Together Building A Better World
Excellent/Very Good/Good (Please circle)
Excellent/Very Good/Good (Please circle)
Excellent/Very Good/Good (Please circle)
2514 Mem v19072014
Rupavahini Muthuhara 2514
Melbourne
Together Building A Better World
5/151, Greensborough Road, Macleod, VIC 3085
Tel.0409 568 547
Email: [email protected]
__________________________________________________________________________________________
3. Are you a member of another children’s club?
4. If ‘Yes’ to question 3, please indicate the name of your club.
Yes/No
Name of the Club:
5. What are your hobbies? How do you spend your leisure time?
6. What are your talents and skills? Please tick the appropriate boxes or add your talents.
For example;
Music (Instruments)
Multi-linguistic Skills
What instruments?
What are the languages?
Singing
Music Composition
Dancing (Bharatha)
Dancing (Ballet)
Dancing (Western & Eastern)
Media (Announcing)
Media (Compeering)
Media (Still photography)
Media (Video Recording)
Editing (Video)
Editing (Sound)
Art (Drawing/ painting)
Art (Craft making)
Art (Designing)
Acting
Script writing
Sports
Debating
Cookery
Computer
Graphic Designing
Public Speaking
7. Have you received any awards?
E.g.: Inter-school, inter-club, state, inter-states or international awards.
8. How did you hear about Muthuhara Melbourne 2514?
9. Why do you want to become a member of Muthuhara Melbourne 2514?
Together Building A Better World
2514 Mem v19072014
Rupavahini Muthuhara 2514
Melbourne
Together Building A Better World
5/151, Greensborough Road, Macleod, VIC 3085
Tel.0409 568 547
Email: [email protected]
__________________________________________________________________________________________
10. If you became a proud member of Muthuhara Melbourne 2514, how would you like to
contribute to its progress?
Parent consent
I consent to the above named member being able to take part in activities* arranged by the 2514 Muthuhara
Melbourne Lama Samajaya and confirm that I am responsible for my child’s safety whilst traveling to and from
the Muthuhara Lama Samajaya.
I have read and understood the 2514 Muthuhara Lama Samajaya Code of Conduct and will ensure that my
child abides by them.
Signature of the Parent/Guardian:
Name:
Date:
CHILD CONTRACT
I have read and understood the 2514Muthuhara Melbourne Lama Samajaya Code of Conduct and I agree to
follow them.
Childs Signature:
Name:
Date:
___________________________________________________________________________
*Cultural/Educational/Religious/Community children activities
Together Building A Better World
2514 Mem v19072014