QCSRA Membership Form 2019

Note: Fields marked (*) are required.

Application Type (*)

Membership status required
Membership Class

Please select a Membership Type
Active Type

Please choose one.
ID number (if known)

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Last name (*)

Please complete Last Name
First name (*)

Please complete First Name
Street Address (*)

Please complete Street Address
Suburb (*)

Please enter Suburb
Post Code (*)

Please enter your Post Code
DOB (dd/mm/yy) (*)

Please enter your Date Of Birth
Age as of the 31st December 2018

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Home phone (xxxxxxxx)

Please enter your Home Phone
Mobile phone number (xxxxxxxxxx)

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Work phone

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Occupation

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Email Address (*)

Please enter a valid Email Address
Secondary email address

Invalid Input Junior members (u18) must include the email address of a parent/guardian in addition to their personal email if not already used for main email address.
Emergency contact name (*)

Please add an Emergency Contact Name
Emergency contact relationship (*)

Please complete Emergency Contact Relationship
Emergency contact phone (*)

Please add your Emergency Contact Phone Number
My 'Working with Children Blue Card/Exemption card' is current. (Required for members 18 years and above).

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Blue Card Number

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Blue card expiry date (dd/mm/yy)

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Please note any club involvement, whether as a player, coach, manager, parent or sibling. (*)

Please complete Club Involvement
In holding membership with the QCSRA, you are agreeing to abide by: (*)

Please select above to accept our Membership Conditions
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I do refereeing as a hobby. Information provided on your membership form may be shared with the QCSRA Management Committee or Match Coaches and/or other QCSRA members where necessary. If you do not want information to be shared please inform the Secretary and Registrar in writing. "I have read and understood the Risk Management Policy. I also understand the role and responsibilities of being a referee as described in the current law book. I am medically and physically able to referee, and perform other physical tasks, including training. I agree that it is my responsibility to seek medical clearance if I am unsure.” Acceptance of membership is subject to obtaining a clearance in accordance with the Commission for Children & Young People (ACT 2000) and any amendments to the ACT thereof. (An "Application for suitability notice for a volunteer" form or proof of compliance must be submitted with this application. Members 18 years and over are required to comply with the Act Copies are available from www.ccypcg.qld.gov.au". I understand that if I fail to lodge a renewal application for the Blue Card at least 6 weeks before the expiry date and subsequently it expires, QSCRA membership will be suspended until such a time my Blue Card is renewed.

In pressing submit, you confirm that all information provided is true and correct. It is your responsibility to notifiy the Secretary of any changes to any details ASAP.