V.c.c.a. Membership & Professional Indemnity Insurance Renewal Notice 2010

V.C.C.A. MEMBERSHIP & PROFESSIONAL INDEMNITY INSURANCE RENEWAL NOTICE 2010 Please Update your Details as Necessary – if expiry dates are incorrect, please resend us a copy: Name: Ms Ashleigh Kimpton Address: 6 Yale Court, Sunbury, 3429 Home phone: 9744 5069 Work phone: Mobile phone: 0407 808 968 Primary E-mail address: [email protected] Alternate E-mail address (backup): Please circle: Yes! I wish to have a 9% discount on membership fees and receive correspondence via email. No. I wish to pay full price VCCA membership fees and receive correspondence via normal post. Note: If you do not circle an option, and have supplied an email address, you will automatically receive correspondence via email. Don’t forget to advise the VCCA if your email address changes throughout the year.

Name of Club/College that you coach/assist at: Sections that you are coaching/assisting: Category of membership: Your Australian Sports Commission (ASC) Number is: Your ASC Level 1 or 2 expires on: Your First Aid expires on: Your Working With Children Check expires on: You purchased your copy of the ACF technical guide on: You attend member’s forums at the following branch: You are registered as a CVI competitor with:

Sunbury T C

06/10/08 Melb

Legend Section

T = Tinies, Su = Sub-Juniors, J = Juniors, I = Intermediates, Sr = Seniors, So = Solos, Sk = Skills R = Recreational, M = Recharge/Masters/Ladies, NCC = Not currently coaching

Category:

2= 1= C= R= A=

Branch:

Melb = Melbourne, Bell = Bellarine, Nth = Northern, W’port = Westernport, B’Dist = Border District

Member who is fully qualified Level ASC Level 2 coach. Member who is fully qualified Level ASC Level 1 coach. Cadet member and unqualified coach even if they have commenced the Level 1 course. Recreational coach who is undertaking or has completed the Recreational Level 1 course. Associate member who is not currently coaching or is retired, and has current or expired Level 1 or 2 qualifications

Make cheque / money order made payable to VCCA and ensure that the name and address of each member is written on the back of your payment. If you require a receipt, please include a stamp self-addressed envelope so that one may be forwarded. Cheques will only be accepted if accompanied by this form.

Please Turn Over to Complete The Form

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ANNUAL MEMBERSHIP RENEWAL for 1 January to 31 December 2010.

All fees are inclusive of GST.

PLEASE READ ALL OPTIONS AND CIRCLE THE ONE THAT APPLIES TO YOU: Category of membership

Fee ($) (incl GST)

Cadet Membership  Category C - Member who will be coaching in 2010 but currently 33 has expired ASC coaching qualifications or has not commenced or completed the Level 1 course Yes! I have supplied my email address and elected to receive correspondence via email so am entitled to 9% off my membership fees!!

To pay

Minus $

(Subtract $3)

Total due and payable by 12 February 2010 (Please make cheque payable to VCCA)

$

Declaration to be signed by ALL members: I, the undersigned, hereby confirm that all the information on this form is correct.

Signed ……………………………………………………………………

Date …………………….

Please send your payment, this signed completed form AND signed ACF Coach’s Code of Ethics Agreement Form (attached) to: VCCA Registrar PO Box 8085 EAST OAKLEIGH 3166.

FORM MUST BE RECEIVED BY FEBRUARY 12th 2010. AFTER THIS DATE A LATE FEE OF $10 WILL APPLY. Information provided on this form will be used for VCCA purposes only.

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