MUBC Member's Sign-Up Form
2011-2012

1. Title Dr Miss Mr Mrs Ms
2. First Name *
3. Last Name *
4. Email Address *
5. Re-type Email Address *
6. Date of Birth *
7. Gender * Male Female
8. Home Address *
9. City *
10. State *
11. Postcode *
12. Country * -- Select Country -- AUSTRALIA AFGHANISTAN ALAND ISLANDS ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CâTE D'IVOIRE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUINEA GUINEA-BISSAU GUYANA HAITI HEARD ISLAND AND MCDONALD ISLANDS HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA, REPUBLIC OF KUWAIT KYRGYZSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, OCCUPIED PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT HELENA SAINT KITTS AND NEVIS SAINT LUCIA SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA AND MONTENEGRO SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN, PROVINCE OF CHINA TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES UNITED STATES MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VENEZUELA VIETNAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA YEMEN ZAMBIA ZIMBABWE
13. Home Phone Number *
14. Work Phone Number *
15. Mobile Phone Number *

1. Emergency Contacts *
   (name, phone, relation)

1. Do you have any medical conditions of which MUBC should be aware? Yes No
2. If yes, please give details
3. Do you have private health insurance? Yes No
4. Do you have ambulance insurance? Yes No
5. What is your Medicare number?
6. Can you swim 50m unassisted
   without stopping in rowing clothes? * Yes No

1. Have you been a member of another rowing club? * Yes No
2. If yes, do you require a transfer? Yes No
3. If yes, what club do you require a transfer from?

1. Student number (current student)
2. Course (current student) Undergraduate Postgraduate
3. Staff/Contractor number
4. Student number and/or Course (alumni)

1. Boat racking required ($75/seat) * Yes No
2. Boat name
3. Boat serial number
4. Oar racking required ($25/set of oars) * Yes No
5. Number of sets of oars

The Members-Only Area is for current paid-up MUBC rowers and MUBC coaches and staff only, and will be used as an important form of communication.

1. Username *
2. Password *
   (must be 6 characters or longer)
3. Confirm Password *

Mailing lists will be an important form of communication. Please subscribe to all mailing lists relevant to you.

1. Members mailing list (for all Members)
2. Men RV/VIS Scholarship mailing list
3. Men Club mailing list
4. Men Youth mailing list
5. Women RV/VIS Scholarship mailing list
6. Women Club mailing list
7. Women Youth mailing list
8. Masters mailing list (for all Masters)
9. Masters Men B/C mailing list
10. Masters Men D mailing list
11. Masters Men E mailing list
12. Masters Men F mailing list
13. Masters Women mailing list

In submitting this form I acknowledge that I have read and agree with the Code of Conduct for the Melbourne University Boat Club (RA version). I also authorise staff and or coaches of the MUBC to consent, where it is impracticable for them to communicate with my emergency contact or myself, for me to receive such medical treatment as may be deemed necessary. I do this understanding that the MUBC staff and coaches will take all reasonable care and responsibility to ensure my safety and well being throughout my participation. In submitting this form I also agree to abide by all club rules as may be in place from time to time. (If under 18 parent or guardian to also agree.)

1. I agree

If you are under 18, please download and print a copy of the Membership Declaration and Participation Agreement (pdf) for you and your parent or guardian to agree and sign, and then return the completed & signed form to the MUBC office as soon as possible.

If you are 18 years or older, please read the Membership Declaration and Participation Agreement (opens in new window) before proceeding further.

1. I am under 18 and will, along with my parent/guardian, complete and return a printed copy of the Membership Declaration and Participation Agreement.
2. I am 18 years or older and have read and understood the Membership Declaration and Participation Agreement (including the warning, indemnity and release) and agree to the terms and conditions as stated.

1. Additional comments
   and information