hayward

wally

hayward

NPO Registration Number: 268-580

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Become an Alpha Centurion Club Member

Name/s

Last name

Date of Birth

Month

Day

Year

ID Number

Gender

Female

Male

Prefer not to say

Occupation

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Please provide your emergency contact's name and surname

Emergency Contact's Cellphone Number

Please provide your emergency contact's relationship

Husband, wife, partner, father, mother, brother, sister etc.

Medical Aid Name

Medical Aid Number

In a medical emergency, should you not be in a mental (semi-conscious / unconscious) capacity to make an informed decision, you give ACAC committee member(s) permission to act on your behalf and to take you to the nearest appropriate emergency room for treatment and provide them with the aforementioned Medical Aid Scheme details as being true and correct.

Consent

Agree

Disagree

Are you an existing or a new member?

I am an existing FULL member, renewing my 2025 membership

I'm a new member

I'm transferring from another club

I'm registering as a social member (NO ASA LICENSE)

When did you join our club?

How many years have you been an ACTIVE member of the club?

If you have not been a member for a few years and rejoined we need to know how many years you were active when we consider long memberships

Transferring members only - Please type your previous club name here

ONLY upload a POP here if you have already paid using an alternative method like EFT

Would you like to donate money towards our Social Responsibility program?

Available funds, where deemed appropriate, are used to fulfil the clubs' initiative towards social responsibility, community goodwill and donations towards training and promotion of disadvantaged athletes.

Social Responsibility Donation

100

250

500

Please upload a head and shoulder photo of yourself (No bigger than 1 MB)

Please upload your ASA application form

Clearance/Transfer letter (ONLY if you are transferring from another club)

I hereby agree to the following:

I hereby apply for membership of Alpha Centurion Athletics Club and agree to abide by the Constitution and Rules of the club, AGN, ASA and the IAAF. A copy of ACAC constitution can be requested from secretary@acrw.co.za. ASA rules and regulations available on www.athleticssa.org.za.

I confirm that all the information provided on this application is true and correct.

I acknowledge that participation in all events organised by the club is at my own risk. The Club will not be liable, whether as a result of negligence or any other reason, for any and all injury, illness or death, resulting from my participating in the sport or any Club or associated activities.

No Full Club Member will represent ACAC unless he/she wears the prescribed club attire, which comprises of our; ACAC sublimated vest or t-shirt and RED pants. This is an ASA and Club rule.

No member of ACAC may participate in the Wally Hayward Marathon, without the consent of the Management Committee.

Social members / members who are not licensed ASA athletes (you did not purchase an ASA permanent license number) are not allowed to purchase or wear ACAC official vest or t-shirt.

Yes, subscribe me to your newsletter.

2025-ASA-PERMANENT-LICENSE-APPLICATION.pdf