Sign up and pay here for the Alpha Centurion Couch to 5k Program

Name/s

Last name

Date of Birth

ID Number

Gender

Female

Male

Prefer not to say

Occupation

Phone

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

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

Membership - You will automatically become a social club member when you join the Couch to 5k program

Sign me up for the Couch to 5k and I want to be Social Member300

I have already done an EFT. I will upload my Proof of Payment0

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)

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.

hayward

wally

wally

hayward

NPO Registration Number: 268-580

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Sign up and pay here for the Alpha Centurion Couch to 5k Program