WDFUA Membership Application Form

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WDFUA Membership Application/Registration (Umpires) 2023 Season

I hereby express my interest to be employed as a casual umpire and a member of the Warrnambool & District Football Umpires Association Inc. *

I understand that the WDFUA annual membership fee of $25.00 (adult) and $10.00 (junior – any person under the age of 18 years as at 1st April 2023 in accordance with WDFUA rules) or $5 for social members can be: *

Deducted from umpiring match payments
Pay cash
Direct Deposit into WDFUA South West Credit account

BSB: 803 073 Account Number 100001187 Please place your name in the Reference box if paying by Direct Deposit.

Address *

Town *

Postcode *

Home Phone

Business Phone

Mobile Phone *

Date of Birth *

Emergency contact *

Phone *

Relationship *

Emergency contact

Phone

Relationship

Email address for Association correspondence and umpire appointments: *

If under 18 please provide parent or guardian's email address

Type of Umpire: *

Field
Boundary
Goal
Social Member

Vehicle Availability to drive umpires to games: *

Yes
No

Driver Licence No. *

Please specify vehicle type and registration number: *

How many seats available in car *

Comprehensive Vehicle Insurance: *

Yes
No

If yes to availability, I agree to abide by road laws set by the Road Safety Act 1986 and drive in a safe manner not endangering any passengers.

Ambulance Cover: *

Yes
No

Membership No. *

Do you have any pre-existing injuries / illnesses which could be affected by the nature of your employment as an umpire e.g. asthma? *

Yes
No

If yes please state: *

Please Note: You may also be required to sign the notice in accordance with Section 82(7) of the Accident Compensation Act 1985.

Do you have a Working With Children Check? *

Yes
No

Working With Children Check number: *

Expiry date: *

Upload a copy of Working with Children card *

Click or drag a file to this area to upload.

If you answered no to the above question, do you agree to apply for a Working With Children Check as required under the Working with Children Act 2005? *

Yes
No
Not Applicable

Only applicable to those over the age of 18.

Reason for no or not applicable *

If you already have a Working With Children Check I agree to have the WDFUA included as one of the notifiable employers: *

Yes
No

Only applicable to those over the age of 18.

I agree not to use electronic and social media to be derogatory to the WDFUA and its members: *

Yes
No

I agree and give permission for the WDFUA (appointed coaches and observers only) to use electronic devices to video me and/or my children at training and/or during a football game for training and coaching purposes only. *

Yes
No

I agree to and provide permission for the use of photographs and names for the purpose of media releases, newspaper articles, newsletters and general promotional material within the discretion of the WDFUA committee and/or coaches. *

Yes
No

I agree to allow my contact details (phone number) be shared in association appointments for other umpires to contact me if I am the driver of the vehicle transporting umpires to games. *

Yes
No

Name of Parent / Guardian (if Applicant is under 18 years of age):

BANK DETAILS

Preferred bank account is the South West Credit Union (SWCU) which has been our Major Sponsor with the Association for over 40 years.
Whilst not compulsory it would be appreciated if you would support our Major Sponsor by applying for a SWCU account.

Are you a member of South West Credit? *

Yes
No

Your member number: *

Account Holder's Name *

Account number: *

Would you like to join South West Credit? *

Yes
No

We will pass your details onto South West Credit and they will be in touch.

OTHER BANK DETAILS

For Payroll Information Only.

Bank name: *

Account Name *

BSB *

ACC No *

If a student, please state name of school:

(Note: This information may be used by the WDFUA for recruitment purposes only).

Please Note:

Under Privacy legislation the information obtained in the above will only be available to affiliate bodies i.e. AFL Country Victoria.

For General Information.

Members are able to have deductions made from weekly pays to assist with costs associated with end of year functions. If you wish this to occur please see Jamie Lake, Payroll Officer.

I declare that the information supplied on this Membership Form is true and correct in every particular. *

Phone