Skate Victoria Roller Disco Participant Membership Form
I hereby apply for membership of Skate Victoria Inc. In so applying and in consideration of my application being accepted I have read, acknowledged and agreed to the declaration including in the warning, exclusion of liability release and indemnity clauses on this form.
I acknowledge that Skate Victoria may reject this application at its discretion.  
I acknowledge that if my application for membership is successful I will be entitled to all benefits, advantages and services of membership for the date the membership is valid.

NOTE: Participants are only eligible to participate in affiliated club's/provider's roller disco activities.

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Date membership is valid for *
Enter the date of the roller disco session you are attending. Participants must submit a membership form for each seperate roller disco activity they participate in. Contact the club/provider you are attending for the correct date to enter.
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Given Name *
Surname *
Address *
If applicant is under 18 years of age, please list the applicant's parents or guardians address.
Phone number *
If applicant is under 18 years of age, please list the applicant's parents or guardians contact number.
Email address *
If applicant is under 18 years of age, please list the applicant's parents or guardians email address.
Date of Birth *
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DD
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Gender *
Select the state your Club/Group is located in: *
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