AUSTRALIAN CAPITAL TERRITORY

APPLICATION FOR MEMBERSHIP AND REGISTRATION AS A BOXER

Name
Address
Email address
Phone number/s
Gym/club
Gender / Date of birth / Blue Book Number (renewing boxers only)

Application for membership and registration

I hereby apply for membership of Boxing ACT Inc.

I hereby apply for registration with Boxing ACT Inc as a BOXER.

In consideration of membership and registration being granted to me, I declare that

(A) I am a resident of Australia. (B) I am of good character. (C) I am not insane or of unsound mind. (D) I am not the subject of any current resolution of suspension, disqualification, or expulsion, imposed by Boxing Australia Ltd or a member association of Boxing Australia Ltd. (E) I understand that my application for membership is subject to the approval of the Committee of Boxing ACT.

Agreement

In consideration of membership and registration being granted to me, I give the following undertakings.

(A) I agree to be bound by the statutes, by-laws, rules and codes of the International Association of Boxing Associations (AIBA), as amended from time to time. (B) I agree to be bound by the constitution, regulations, policies, by-laws, rules and codes of Boxing Australia Ltd, as amended from time to time. Including the Coaches Code of Ethics. (C) I agree to be bound by the constitution, regulations, policies, by-laws, rules and codes of Boxing ACT Inc, as amended from time to time. Including, the Code of Conduct and the Sparring Safety Policy. (D) I agree to be bound by, and comply with, the Anti-Doping Regulation and associated policies of Boxing Australia Ltd, as amended from time to time. I agree that this regulation may be enforced against me. Boxing Australia Ltd may request samples from me for testing, and where appropriate, may discipline me, in accordance with this regulation. (E) I agree to be bound by, and comply with, the Personal Protection Regulation and associated policies of Boxing Australia Ltd, as amended from time to time. I agree that this regulation may be enforced against me. Boxing Australia Ltd may conduct investigations, and where appropriate, may discipline me, in accordance with this regulation. (F) The information I have or will provide to Boxing ACT Inc may be used to administer my membership, and may be provided to Boxing Australia Ltd and its member associations, Australian Sports Commission, Australian Institute of Sport, Australian Olympic Committee and other organisations as necessary and appropriate. (G) I consent to my information, and any photo or image of myself, being published on the Boxing ACT website. (H) If I wear contact lenses in competition, I will only wear soft lenses. If I wear orthodontic braces in competition, I will use a dentist-moulded mouthguard.

Acceptance of risk, waiver and release

(A) I understand that participating in fitness training and boxing activities carries risk to me (and if pregnant my baby) of illness, infection, serious injury and death. I acknowledge and I voluntarily and knowingly accept this risk. I understand that the risk of contracting blood borne disease, for instance Hepatitis B, may be reduced or eliminated by my being vaccinated. (B) I accept sole responsibility for ensuring that I am medically, mentally and physically fit to participate in fitness training and boxing activities. I will notify my coach or trainer of any matter which may affect my fitness to participate in fitness training and boxing activities. (C) If I observe or become aware of any hazard, I undertake to remove myself from the hazard, safeguard others from the hazard, and immediately notify my coach, trainer or club or gym official.

On behalf of myself, my baby (if applicable), my heirs and successors and my legal representatives, I waive and release BoxingACT, its Committee members, employees, officers, officials, medical officer, volunteers, coaches and boxers from all claims and liability in any way related to such illness, infection, injury or death.

Insurance

The Boxing Australia Insurance Program provides limited and conditional cover to members of Boxing ACT. Terms and conditions apply, including restrictions, maximum benefits limits, and excess and exclusions, etc. Further information, including terms and conditions, are available on the Boxing Australia website, or from the broker.

Declaration
I have read this agreement and waiver and I execute it with full understanding of its significance
(boxer signature) (date)
Parent or Guardian Declaration (for applicants under 18 years)
I am the parent or guardian of the applicant. I have parental authority for the applicant. I consent to the applicant participating in fitness training and boxing activities. I have read this agreement and waiver and I execute it, for and on behalf of the applicant, with full understanding of its significance.
(Parent/guardian signature) (date)

Payment

Annual membership and registration fee adults $130 under 18s $95

Direct deposit to Westpac Bank, account name Boxing ACT Inc

BSB 032 636 Account 236 365

Please include your name for reference, and scan and send a copy of receipt withthis form.

When you have completed and signed this form, scan and send to Boxing ACT, together with scans of your birth certificate or passport, and a passport photo.