Membership Application

Transcription

1 Membership Application YMCA OF CENTRAL AUSTRALIA INC. PO Box 2458, Sadadeen Rd, Alice Springs NT 0871 Telephone: (08) Facsimile: (08) Personal Details Title: Surname: Preferred Name: Date of Birth: / / Sex: M / F (Please circle) Home Address: P/Code: Phone (h) (w) (m) Previous Member: Yes / No Emergency Contact Details Name: Relationship: Phone (h) (w) (m) I,, hereby agree to abide by all rules and regulations of the YMCA of Central Australia and agree to pay the applicable membership fees. 0 I understand my membership is non-transferable and fees are subject to change. 0 I understand that my membership may be suspended for a maximum of 8 weeks per annum. A $10 fee is applicable per each suspension. Memberships are refundable only within 7 days of purchase, minus an administration fee or will be considered on presentation of an appropriate medical certificate. ADULT DECLARATION I hereby agree that the YMCA and its officers, leaders, staff and agents shall be released from and shall not incur any responsibility or liability for any accident or injury sustained by me or for any damage to or loss of my property. I further authorise you to obtain at my cost medical/ambulance assistance in the case of an accident or emergency involving me. Signature: Date: / / Office Use Only: Staff Initials: M/Ship Type: M/Ship No.: Membership added to tally: Members added to address book:

2 YMCA OF CENTRAL AUSTRALIA INC. PAR-Q FORM The PAR-Q (Physical Activity Readiness - Questionnaire) form is designed to assess whether you need a medical clearance before you commence an exercise program or increase your current level of physical activity. Please read each question carefully and answer them to the best of your knowledge. 1. Has your doctor ever said you have heart trouble? YES NO 2. Do you frequently suffer pains in your heart or chest? YES NO 3. Do you often feel faint or have spells of severe dizziness? YES NO 4. Has your doctor ever said your blood pressure is too high YES NO (over 145/90 mmhg)? 5. Has your doctor ever said that you have a severe bone, joint or YES NO muscle problem such as arthritis that has been aggravated by exercise or might be made worse be exercise? 6. Are you pregnant? YES NO 7. Are you over the age of 50? YES NO 8. Is there any other physical reason not mentioned here which YES NO may cause serious harm by exercising? If you answered YES to any of the above questions you are required under the guidelines of YMCA of Central Australia Inc and Active Australia, to consult a doctor for a medical clearance prior to participating in our Health Club Active Australia also recommends that the following people should consult a doctor to obtain a medical clearance: People with chronic health problems, such as heart disease, diabetes, or obesity, or who are at high risk for these problems and beginning a new program of physical activity. Older people returning to competitive or strenuous physical activity, whether or not they have a history of or risk factors for cardiovascular disease. The YMCA acknowledges and respects the privacy of individuals. The information that is being collected on this document is for the purposes of providing you with an appropriate exercise plan specific for your needs. The personal and health information collected is required to determine preexisting conditions, which may influence your ability to participate in a program. By completing this form, the YMCA accepts that you, your parents/guardians (if a person under the age of 18) have consented for this information to be collected. The intended recipients of this information are the YMCA, and its authorised staff. You have the right to access and alter personal or health information concerning in accordance with the Commonwealth Privacy Act (Amended 2001) and YMCA Privacy Policy. As part of your membership/ enrolment with the YMCA, you will receive information from time to time regarding our programs and services. The YMCA may also provide promotional material from our strategic partners, or any other third party, if you do not wish to receives this information please tick the " OPT OUT" box below and return this to the YMCA. Your name will be removed from the mailing list within a reasonable period of time. OPT OUT....../.../ Signed Date Witness / Instructor

3 ABN: Direct Debit Request (DDR) Authorisation Form Updated in Links Change added to tally added/removed CUSTOMER DETAILS Cust: Ref #: Given Name: Surname: (Or Company Name) Address: Street Name and Number City State P/code Telephone: Mobile Work Phone Home Phone PAYMENT ARRANGEMENT For the total amount billed for the specified period for this and any other subsequent agreements or amendments including associated fee/charges as detailed. Single Payment: Recurring Payment: / / debit the amount of: $ debit the amount of: $,. Payment Frequency: Weekly Fortnightly Monthly ( Payment Term: (Select one only) Continue until further notice Until I have paid $. OR regular payments Transaction Fee Direct Debit: $0.65 Credit Card: Visa/Mastercard 1.50% (min $0.65) BANK ACCOUNT AUTHORISATION Direct Debit is not available on the full range of accounts if in doubt please refer to your financial institution Financial Institution Branch BSB Number Account Number 9 Digits MAX Account Holder Name I / We authorise LinksPay Pty Ltd ABN , User ID , to debit my/our account at the Financial Institution identified above through the Bulk Electronic Clearing System (BECS) in accordance to the Payment Arrangements stated above and this Direct Debit request and as per the DDR Service Agreement provided. CREDIT CARD AUTHORISATION Please charge my periodical payments to my (please tick one): VISA MasterCard Amex Card Number Name on Card (exactly how it appears on card) Expiry Date / M M Y Y This Authorisation is to remain in force in accordance with the Terms and Conditions on this Direct Debit Request, the provided DDR Service Agreement, and I/we have read and understand the same. X AUTHORISING SIGNATURE Date / / Ver: 19

4 ABN: DDR Service Agreement This Agreement is designed to explain what your obligations are when undertaking a Direct Debit arrangement with LinksPay and the Business. It also details what our obligations are to you as your Direct Debit Provider. We recommend you keep this agreement in a safe place for future reference. It forms part of the terms and conditions of your Direct Debit Request (DDR) and should be read in conjunction with your DDR form I/We hereby authorize LinksPay Pty Ltd (ABN: ) Direct Debit User ID to make periodic debits on behalf of the Business as indicated on the front of this Direct Debit Request (herein referred to as the Business) I/We acknowledge that LinksPay is acting as a Direct Debit Agent for the Business and that LinksPay does not provide any goods or services and has no express or implied liability in regards to the goods and services provided by the Business or the terms and conditions of any agreement with the Business. I/We acknowledge that LinksPay and the Business will keep any information (including account details) contained in the Direct Debit Request confidential. LinksPay and the Business will make reasonable efforts to keep any such information that we have about you secure and to ensure that any of our employees or agents who have access to information about you do not make any unauthorised use, modification, reproduction or disclosure of that information. We will only disclose information that we have about you: (a) to the extent specifically required by law; or (b) for the purposes of this agreement (including disclosing information in connection with any query or claim). I/We acknowledge that the debit amount will be debited from my/our account according to the Direct Debit Request, this Agreement and the terms and conditions of the agreement with the Business. I/We acknowledge that bank account details have been verified against a recent bank statement to ensure accuracy of the details provided. If uncertain you should contact your financial institution. I/We acknowledge that is my/our responsibility to ensure that there is sufficient cleared funds in the nominated account by the due date to enable the direct debit to be honoured on the debit date. Direct debits normally occur overnight; however transactions can take up to three (3) business days depending on your financial institution. I/We acknowledge and agree that sufficient funds will remain in the nominated account until the direct debit amount has been debited from the account and that if there are insufficient funds available, I/We agree that LinksPay will not be held responsible for any fees and charges that may be charged by your financial institution. I/We Acknowledge that there may be a delay in processing if: 1) There is a public or bank holiday on the day, or any day after the debit date 2) A payment request is received by LinksPay on a day that is not a Banking Business Day 3) A Payment request is received after normal operational hours, being 4pm Monday to Friday. Any payments that fall due on any of the above will be processed on the next business day. I/We authorise the Business to vary the amount of the payments from time to time as provided for within the Business agreement. I/We authorise LinksPay to vary the amount of the payments upon instructions from the Business. I/We do not require LinksPay to notify me/us of such variations to the debit amount. I/We acknowledge that the total amount billed will be for the specified period for this and/or subsequent agreements and/or amendments. I/We acknowledge that the Business is to provide 14 days notice if proposing to vary the terms of the debit arrangements. I/We acknowledge that variations to the debit arrangement will be directed to the Business. I/We acknowledge that any request to stop or cancel the debit arrangement will be directed to the Business. I/We acknowledge that any disputed debit payments will be directed to the Business. If no resolution is forthcoming you are advised to contact your financial institution. I/We acknowledge that if a debit is returned by my/our financial institution as unpaid, I/We will be responsible for any fees and charges for each unsuccessful debit in addition to any financial institution charges and collection fees, including and not limited to any solicitor fees and collection agent fees appointed by LinksPay. I/We authorise LinksPay to attempt to re-process any unsuccessful payments as advised by the Business. I/We acknowledge that if specified by the Business, a setup, variation, dishonour, SMS or processing fees may apply as instructed by the Business. I/We authorise: 1) The Debit User to verify details of my/our account with my/our financial institution 2) The Financial Institution to release information allowing the Debit User to verify my/our account details. LinksPay Pty Ltd ABN: P.O Box 6290, Upper Mt Gravatt, Queensland 4122 Ph: Fax:

5 1. INTRODUCTION This document outlines the rights and responsibilities you have with regard to the ability of YMCA OF CENTRAL AUSTRALIA INC. to directly debit your nominated bank account for any instalments or fees due by you under the terms and conditions of the Contract and DDR Service Agreement, the terms of which are stated below. Should you have queries regarding your Contract or this DDR fo rm you should in the first instance contact YMCA OF CENTRAL AUSTRALIA INC. on PHONE NO YMCA OF CENTRAL AUSTRALIA INC. Contract & Client Service Agreement 2. PAYMENTS YMCA OF CENTRAL AUSTRALIA INC. will debit your nominated account for the amount and at the frequency of payments as agreed between us on the YMCA OF CENTRAL AUSTRALIA INC. DDR Contract signed and accepted by you. If the nominated day of your debit falls on a public holiday or weekend, YMCA OF CENTRAL AUSTRALIA INC. will debit your account on the next business day. It is your responsibility to have clear funds in your account on the due date of the direct debit. The customer agrees to pay the instal ment amount at the agreed payment frequency until this Contract is terminated in accordance with clause 4 below. Should there be any arrears in payments the Customer authorises YMCA OF CENTRAL AUSTRALIA INC. to debit the outstanding balance in order to bring the account up to date. The contract of membership can be voided within 7 days of joining and total monies refunded without further obligation. All terms and conditions of membership are binding after 7 days. 3. SUSPENSION FOR MOST MEMBERSHIPS Suspension of payments is possible under the terms of your Contract. Payments may be suspended for a minimum of two weeks and a maximum of 8 weeks at a time. Suspension requests must be made 3 days prior to the next direct debit by completing a Customer Request form or ed directly to YMCA OF CENTRAL AUSTRALIA INC. at reception.ca@ymca.org.au. A charge of $10 suspension applies. All medical suspensions are free upon presentation of a valid doctor s medical certificate. 4. CANCELLATION The Customer may cancel this Contract by completing a Customer Request Form if all the fees due up to the date of termination are paid in full. A period of 3 days notice must be given before the due date of the next debit to terminate that payment; or the next full membership payment will be deducted. Please note, memberships are ongoing. Your account will continue to be debited until an amendment form has been completed with notice of cancellation. Monthly fees are non refundable. 5. YOUR OTHER RESPONSIBILITIES In addition to those already mentioned, you are responsible for ensuring that your nominated account is able to accept direct debits. If it is not, it is your responsibility to provide YMCA OF CENTRAL AUSTRALIA INC. with a new account number. You are responsible to notify YMCA OF CENTRAL AUSTRALIA INC. of any changes to your debit details or contact details by completing a Customer Request form or contact YMCA OF CENTRAL AUSTRALIA INC. at reception.ca@ymca.org.au. The member is responsible to forward all correspondence on to the bank or debit account holder. 6. DISHONORED PAYMENTS Should your payment be dishonoured, YMCA OF CENTRAL AUSTRALIA INC. will debit you an additional $15 with your next payment and, if we have not received instructions to the contrary from you, debit both the current due payment and the now overdue payment(s) on the same day. In the event of payments being dishonoured on two consecutive occasions YMCA OF CENTRAL AUSTRALIA INC. reserves the right to terminate your Contract. YMCA OF CENTRAL AUSTRALIA INC. may charge any other fees or costs involved with debit collection. 7. INCREASE IN FEES AND CHANGE OF TERMS YMCA OF CENTRAL AUSTRALIA INC. may at any time upon sending written notice to the customer s last known address and giving 30 days notice, increase the instalment amount. In the event that the initial terms are to change, they can only do so in accordance with your contract a nd we must give you at least 14 days notice of the changes including if applicable new frequency and next debit date. If you have any questions on proposed changes, please contact your chosen YMCA Branch. 8. DISPUTES All disputes regarding a direct debit payment should be referred to YMCA Membership Response Service by phone , reception.ca@ymca.org.au or in writing. 9. AVAILABILITY OF SERVICES YMCA OF CENTRAL AUSTRALIA INC. reserves the right to alter the operational hours or provision of available services at any time without notice. 10. ENTITLEMENT The Customer acknowledges that provision of services provided by the Branch may change and for the purposes of this Contract is based on entitlement to use and not on actual use. The customer agrees to be bound by the rules and conditions of the Branch. The Branch and /or YMCA OF CENTRAL AUSTRALIA INC. may terminate entitlement of the use of the Branch if any Customer fails to comply with the rules of conduct of the Branch or fails to make payment of any fee on the due date. 11. PROVISION OF SERVICE Change of location or ownership or the name of the Branch does not absolve the Customer of responsibilities under the terms and conditions of this Contract. 12. CREDIT/DEBT REPORTING AGENCIES THE Customer authorises YMCA OF CENTRAL AUSTRALIA INC. to notify any debt collection/credit-reporting agency upon default by the Customer in regard to any obligation under this Contract. Should this occur then at YMCA OF CENTRAL AUSTRALIA INC. sole discretion, it may terminate the contract at which time the full outstanding balance for the remainder of the minimum term or payments including any current arrears shall be immediately due in full. In addition YMCA OF CENTRAL AUSTRAL IA INC. shall add $30 to the outstanding debt as its fee for dealing with the defaulting member. The Customer authorises YMCA OF CENTRAL AUSTRALIA INC. to add any further amount to the outstanding debt that might be reasonably incurred by YMCA OF CENTRAL AUSTRALIA INC. in collecting the outstanding debt. This further amount shall include the fees of the agency to which the account is referred, which are based on the total amount collected by them. 13. ENTIRE AGREEMENT This Contract and DDR Service Agreement constitute the entire agreement, understanding and arrangement (express and impli ed) between the Customer, the Branch and YMCA OF CENTRAL AUSTRALIA INC. relating to the subject matter of this Contract and supersede and cancels any previous agreement, understanding and arrangement relating thereto whether written or oral. 14. PRIVACY The YMCA OF CENTRAL AUSTRALIA INC. acknowledges and respects the privacy of individuals. The information that is being collected on this document is for the purpose of servicing your membership subscription and financial institution payments. This information provides accurate personal information in order to carry out the financial transaction requested. The intend ed recipients of this information are the YMCA, its authorised staff and contracted service providers, such as financial institutions and Government agencies covered by law. You have the right to access and alter personal information, protecting yourself in accordance with the Commonwealth Privacy Act (Amended 2001), and the YMCA Privacy Policy. If you do n ot wish to have your information used or disclosed for this purpose, the YMCA OF CENTRAL AUSTRALIA INC. will be unable to process your financial transactions. Your account records and details will not be disclosed to any outside person or entity accept in accordance with the rules laid down in the Contract and where such information is required in connection with any claim for an alleged incorrect or wrongful debit. As part of your membership with YMCA OF CENTRAL AUSTRALIA INC., you will receive information from time to time regarding our programs and services. The YMCA may also provide promotional material from our strategic partners, or any other third party, if you do not wish to receive this information please tick the OPT OUT box on the front of the Direct Debit Contract and return to the YMCA. Your name will be removed from the mailing list within a reasonable period of time. 15. LIABILITY To the extent permitted by law, the Branch and YMCA OF CENTRAL AUSTRALIA INC. shall not be liable or responsible to the Customer for any direct, indirect or consequential injury, loss or damage to the Customer whatsoever and howsoever arising. Should this contract relate to payments for the entitlement to use fitness, health or aquatic facility, the Customer acknowledges that with any physical activity, as is likely to be carried out by the Customer at the Branch, there is a risk of both minor and major accidents, injury and death. Understanding and acknowledging this risk, the Customer agrees to use the Branch at their own risk.