Membership Form

1Membership Type

2Participant 1 Details

3Participant 2 Details

4Participant 3 Details

5Participant 4 Details

6Participant 5 Details

7Participant 6 Details

8Participant 7 Details

9Participant 8 Details

10Participant 9 Details

11Participant 10 Details

12Support Agency

13Emergency Contact

14Consent

15Payment

Type of Membership

Membership Type*

All memberships are inclusive of GST and no weekly participation fee is charged.

How many in your family?*

How many in participants will you be registering?*

I am interested in:

Supported Sailing- Wednesday- Dinghy

Supported Sailing- Wednesday- Keelboat

High Support Sailing- Thursday- Dinghy

High Support Sailing- Thursday- Keelboat

High Support Sailing- Thursday- Nev Thomas powerboat

Social Sailing on a Sunday

Learn to Sail

School Group or Group Sailing Events

Club Racing

Blind Sailing

Volunteering

Supporting Sailability

What Supported Sailing time would you like to book into?

Wednesday at 10AM- Dinghy (5 places)

Wednesday at 11AM- Dinghy (5 places)

Your preference will be noted for a day and time to sail with us. Please understand that places are limited for our supported sailing days. Our sailing co-ordinator will confirm the day and time you are ‘booked in’ for by email.

What Supported Sailing time would you like to book into?

Wednesday at 10AM- Keelboat (6 places)

Wednesday at 11AM- Keelboat (6 places)

What Supported Sailing time would you like to book into?

Thursday at 10:30AM- Dinghy (2 places) High support

What Supported Sailing time would you like to book into?

Thursday at 10:00AM- Keelboat (4 places) High support

Thursday at 11:00AM- Keelboat (4 places) High support

Please complete participant details for EACH participant.

Participant 1 Details

Participant Name*

Prefix First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Phone Number

Mobile Number

Email address for general correspondence*

What is the nature of your disability, and any support you may require?

Participant Statement*

I am aware of the nature and involvement of the supported sailing activity and accept that participation is entirely at my own risk.

Carer Statement

I understand that as a responsible carer for the above-named participant, I am aware of the nature and involvement of the supported sailing activity. I give my permission, for them to participate and accept that participation is entirely at their own risk.

Carer's Name

First Last

Relationship / position

Carer's Contact Number

Participant 2 Details

Participant Name*

Prefix First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Phone Number

Mobile Number

Email address for general correspondence*

What is the nature of your disability, and any support you may require?

Participant Statement*

I am aware of the nature and involvement of the supported sailing activity and accept that participation is entirely at my own risk.

Carer Statement

Carer's Name

First Last

Relationship / position

Carer's Contact Number

Participant 3 Details

Participant Name*

Prefix First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Phone Number

Mobile Number

Email address for general correspondence*

What is the nature of your disability, and any support you may require?

Participant Statement*

I am aware of the nature and involvement of the supported sailing activity and accept that participation is entirely at my own risk.

Carer Statement

Carer's Name

First Last

Relationship / position

Carer's Contact Number

Participant 4 Details

Participant Name*

Prefix First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Phone Number

Mobile Number

Email address for general correspondence*

What is the nature of your disability, and any support you may require?

Participant Statement*

I am aware of the nature and involvement of the supported sailing activity and accept that participation is entirely at my own risk.

Carer Statement

Carer's Name

First Last

Relationship / position

Carer's Contact Number

Participant 5 Details

Participant Name*

Prefix First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Phone Number

Mobile Number

Email address for general correspondence*

What is the nature of your disability, and any support you may require?

Participant Statement*

I am aware of the nature and involvement of the supported sailing activity and accept that participation is entirely at my own risk.

Carer Statement

Carer's Name

First Last

Relationship / position

Carer's Contact Number

Participant 6 Details

Participant Name*

Prefix First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Phone Number

Mobile Number

Email address for general correspondence*

What is the nature of your disability, and any support you may require?

Participant Statement*

I am aware of the nature and involvement of the supported sailing activity and accept that participation is entirely at my own risk.

Carer Statement

Carer's Name

First Last

Relationship / position

Carer's Contact Number

Participant 7 Details

Participant Name*

Prefix First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Phone Number

Mobile Number

Email address for general correspondence*

What is the nature of your disability, and any support you may require?

Participant Statement*

I am aware of the nature and involvement of the supported sailing activity and accept that participation is entirely at my own risk.

Carer Statement

Carer's Name

First Last

Relationship / position

Carer's Contact Number

Participant 8 Details

Participant Name*

Prefix First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Phone Number

Mobile Number

Email address for general correspondence*

What is the nature of your disability, and any support you may require?

Participant Statement*

I am aware of the nature and involvement of the supported sailing activity and accept that participation is entirely at my own risk.

Carer Statement

Carer's Name

First Last

Relationship / position

Carer's Contact Number

Participant 9 Details

Participant Name*

Prefix First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Phone Number

Mobile Number

Email address for general correspondence*

What is the nature of your disability, and any support you may require?

Participant Statement*

I am aware of the nature and involvement of the supported sailing activity and accept that participation is entirely at my own risk.

Carer Statement

Carer's Name

First Last

Relationship / position

Carer's Contact Number

Participant 10 Details

Participant Name*

Prefix First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Phone Number

Mobile Number

Email address for general correspondence*

What is the nature of your disability, and any support you may require?

Participant Statement*

I am aware of the nature and involvement of the supported sailing activity and accept that participation is entirely at my own risk.

Carer Statement

Carer's Name

First Last

Relationship / position

Carer's Contact Number

Support Agency

If your membership does not require a support agency, please hit NEXT

Support Agency

Name

Prefix First Last

Emergency Contact

Emergency Contact*

Emergency Mobile Number

Emergency Phone Number

Email Address

Consent

Acknowledgement of rules and safety regulations*

I understand that Sailability WA Inc. has rules for the safety of its participants. As a Member of this association, I will adhere to the rules and safety regulations at all times.

To become familiar with the safety rules, please download the Operations Safety Manual here.

Support person / carer*

I understand for Supported Sailing activities, a participant must attend with a support person/ carer.

Photography consent

I am aware that Sailability WA may use my image in promotional materials, including social media (If you have an objection please contact the Sailability WA coordinator).

Payment

If you would like to add the purchase of a Personal Floatation Device (life jacket) please select the quantity required.

Personal Floating Device

Price:

Quantity

Total Membership Cost

Comments

This field is for validation purposes and should be left unchanged.

Be a part of Sailability WA Inc.

Membership Form 2023/2024

Type of Membership

Participant 1 Details

Participant 2 Details

Participant 3 Details

Participant 4 Details

Participant 5 Details

Participant 6 Details

Participant 7 Details

Participant 8 Details

Participant 9 Details

Participant 10 Details

Support Agency

Emergency Contact

Consent

Payment

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