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MEMBERSHIP APPLICATION
FOR THE YEAR
1 APRIL 2015 TO 31 MARCH 2016
CATEGORY
GRADE CODE
Qty
AMOUNT
Club Membership plus Athletics Waikato BOP and Athletics NZ Membership
Men/Women
20 years plus (SM or SW: MM or MW) $80.00
___
$___________
(The above fee applies to all aged 20 years and above including Running/Walking Clinic members)
Men/Women 20
Men/Women 17
Boys/Girls
Boys/Girls/Tiny Tots
18, 19 yrs
15, 16, 17 yrs
7 -14 yrs
2 - 6 yrs
(JM or JW)
(B or G - boy/girl)
(B or G)
(B or G)
Honorary (elected by LCAC)
Apparel
$63.00
$63.00
$45.00
$30.00
HO
Adults Walkers Tee (short sleeves)
Adults Runners Singlets
Adults Track Suit Sets (M-XXL)
Juniors Runners Singlets (Size 4-14)
Junior Track Suit Sets (Size XXS-M)
___
___
___
___
$___________
$___________
$___________
$___________
___
___
___
___
___
$___________
$___________
$___________
$___________
$___________
Nil
$35.00
$35.00
$90.00
$15.00
$50.00
Total including GST
$___________
Paid by (circle one) Cheque / Cash / Internet Banked date, name, and ref: ________________________________
Please circle – The primary area of the club I/we are interested in participating in is: Children’s summer athletics / Teens and
adults (12 years plus) summer athletics / Walking / Running clinic / Running in general
RUNNING CLINIC: For first-time members, your membership will cover you from the Clinic start being the 3rd week of January,
through to and including the full financial year in which the Rotorua Marathon takes place.
 Recommended GP health check visit for the purposes of Marathon training (circle one) - Done / No / Will do
 What distance events have you completed before ( circle one) - Marathon / Half Marathon / 10km / 5km / None
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GENERAL NOTES:
1)
Those aged 14 and under will be issued with a Colgate “flash” to be sewn onto the left shoulder of your Club uniform. All
other members will receive a Lake City Athletic Club Inc membership card once your membership payment has been
processed. You should allow the Club at least two weeks to process your application.
2)
Athletics New Zealand age grades: Age grades for Children (up to 14yrs) are based on age as at 31st December in the
year of Membership shown above. Grades for Men & Women (15-34yrs) is age as at 31st December of the calendar year
you are currently in (will change at the beginning of each year). Grades for masters (ages 35+) competing in Masters
Athletics events, grade is determined by age on the day.
3)
Please pay your membership by cheque payable to The Lake City Athletic Club Inc, or the exact cash
amount, or pay by internet transfer to the club’s Westpac bank account # 03-1552-0095487-00. You must
record your name (first and surname) as a reference on the transfer.
No matter which method of payment is used this form completed and signed must be forwarded to the
Club by postal mail (P O Box 2136, Rotorua, 3040), or scanned and emailed to [email protected] before
your application can be processed.
If a 3rd party is paying for you it is extremely important that there is indication that the payment is on your
behalf.
PTO
www.lakecity.co.nz
PO Box 2136, Rotorua
Membership Form - (Please print neatly and ensure that all fields below have been completed).
Person 1
Person 2
Person 3
First Name
Surname
Age
Date of Birth
Male/Female
(Circle)
New Member?
Y/N
Person 4
Age
Male/Female
Age
New Member?
Y/N
Male/Female
Person 5
New Member?
Y/N
Person 6
First Name
Surname
Age
Date of Birth
Male/Female
(Circle)
New Member?
Y/N
Age
Male/Female
Age
New Member?
Y/N
Male/Female
New Member?
Y/N
ADDRESS (Street etc)
Town/City / Postal
code
Phone Numbers (all)
Email Address(es)
Parent/Guardian
Names
Occupations (optional)
Privacy Act 1993
I hereby apply to join the Lake City Athletic Club (Inc) and agree to abide by its rules as stated in its Constitution. I also agree, in
compliance with the Privacy Act 1993, that my personal details as outlined in this Application Form be made available to Athl etics
New Zealand either through Athletics Waikato Bay of Plenty or direct, for the purpose of its administration of the sport of athletics
in New Zealand. I acknowledge the Club’s lawful right to periodically take photographs at club night activities and/or other events
for ongoing marketing purposes on its website, Facebook, and other media. However, the Club will remove any photo(s) that I
specify, that may cause me harm or is offensive in nature.
All persons age 16 and over to sign below separately
Signed: - .............................................……................………….............................
Date:-…………………………….
Signed: - .............................................……................………….............................
Date:-…………………………….
------------------------------------ Cut here and hand in top section---------------------------------GENERAL NOTES continued…
3)
The Club Uniform: For Adults is either the blue walker’s tee shirt with short sleeves, or the runner’s singlet in blue, white and black. The
club uniform for Children is the children’s running singlet in blue, white and black. These must be worn with plain black shorts or plain
black lycra legging shorts. Club uniforms can be purchased by arrangement with Nikki Mitchell Ph 027 4648546 or Sarah Wiwarena 027
2483874. Please make arrangements for purchase well before you require it. Club members are encouraged to wear club uniform
during all events (e.g. club nights, half marathon, and publicity photos) and must be worn in inter-club events when determined necessary
(e.g. Ribbon Days, and relay events like NZ Road Relays).
4)
Some of the Club’s activities are:
 Children’s athletics (2 years to 11 years inclusive) – these weekly Tuesday evening activities are held at the No 2 Ground of the
International Stadium, Devon Street West, from 5.10pm commencing early October through to the end of March
 Teens and adults athletics (12 years and above) - these weekly Wednesday evening activities are held at the No 2 Ground of the
International Stadium, Devon Street West, from 6.00pm commencing late October through to the end of March
 Running clinic – for runners wishing to train in the company of others with the aim of completing the full Rotorua Marathon, the
Rotorua Half Marathon or 5km and 10km on marathon day. This Clinic commences mid-January and builds up to the annual Rotorua
Marathon in early May
 Walkers clinic - for walkers wishing to train in the company of others with the aim of completing either the full Rotorua Marathon, the
Rotorua Half Marathon or 5 and 10km on marathon day. This Clinic commences early November and builds up to the annual Rotorua
Marathon in early May
 Winter activities - running/walking for all ages (Harriers) - Club events are held in Rotorua most Saturday afternoons from mid-April to
mid-October. There are also Tuesday and Thursday evening and Sunday morning group runs and walks.
5)
Cancellations:
The clubs winter activities and the teens and adults summer athletics rarely cancel, even if it’s raining. The running and walking clinics go
ahead regardless of the weather. The children’s athletics section only cancels if it is heavy rain – please contact the children’s convenor
or check the cancellation notices on www.lakecity.co.nz or the clubs Facebook page
For further information on the Clubs activities visit the website below
www.lakecity.co.nz
PO Box 2136, Rotorua