FORMS

 

FORM 1

COMBINED PROBUS CLUB OF BELMONT CENTRAL INC.

CLUB NO. 9003554  INC. NO. A0052810X

REGISTRATION FORM FOR OUTINS and/or TOURS

2024-25 PROBUS YEAR           

 PARTICIPANTS DECLARATION:

 

Name: …………………………………………………………………………………………………………………………….

 

While participating on Club Outings/Tours:

 

-       I understand that I am the person who is fully responsible for the state of my health and I undertake to do all that is necessary so as not to place other participants under stress or duress or to put them in danger because of the state of my health or my behaviour.

 

-       I hereby declare that to the best of my knowledge I am fit enough to undertake these Outings/Tours and agree to advise the Leader immediately should the state of my health change.

 

-       I hereby declare that I will only participate in activities where I am physically capable.

 

-       In case of any accident, illness or emergency, please contact my next of kin:

 

Name: …………………………………………………………………. Relationship…………………………………………………………….

 

Tel: …………………………………………………………………….    Mobile: …………………………………………………………………..

 

Address: ………………………………………………………………………………………………………………………………………………….

 

…………………………………………………………………………………………………………………………………………………………………

 

Name: …………………………………………………………………. Relationship…………………………………………………………….

 

Tel: …………………………………………………………………….    Mobile: …………………………………………………………………..

 

Address: ………………………………………………………………………………………………………………………………………………….

 

…………………………………………………………………………………………………………………………………………………………………

Privacy Statement: Information provided shall be kept private and confidential within the confines of the Probus Club and shall only be used in the event of an emergency.

 

Signed:……………………………………………………………………… Date: ……………………………………………………………………

 

 

FORM 2

PROBUS SOUTH PACIFIC LIMITED

Accident / Injury / Incident Report Form

 

Probus Club Name ……………………………………………………………………………….

 

Club Number …………………........................ 

                        

Accident             Injury            Incident   (please circle one)

Date of accident / injury / incident …………………………………………………………………………………    Time of accident / injury / incident …………………………………………………………………………………

Was the event where the accident, injury or incident occurred approved by your Probus Club? (please circle) Yes / No   Please note that in the event of an insurance claim, the insurer may require a copy of the minutes where this event was approved by the Probus Club.

Did the accident / injury / incident occur whilst travelling to or from your Club’s approved activity? (please circle) Yes / No   Did the accident / injury / incident occur during your Club’s approved activity? (please circle) Yes / No   Location of accident / injury / incident  ……………………………………………………………………………………………………………………………   ……………………………………………………………………………………………………………………………

Describe the event at which the accident, injury or incident took place i.e. Club meeting or activity   ……………………………………………………………………………………………………………………………   ……………………………………………………………………………………………………………………………   ……………………………………………………………………………………………………………………………

Details of injured person    Name ……………………………………… Membership Number (if applicable) …………………………………             Address …………………………………………………………. Phone Number ………………………………….      Email Address…………………………………………………………………………………………………………    If more than one person was injured as a result of the same incident, please provide their details on a separate page.

Cause of accident / injury / incident   ……………………………………………………………………………………………………………………………   ……………………………………………………………………………………………………………………………   ……………………………………………………………………………………………………………………………   ……………………………………………………………………………………………………………………………   ……………………………………………………………………………………………………………………………   ……………………………………………………………………………………………………………………………   ……………………………………………………………………………………………………………………………   ……………………………………………………………………………………………………………………………

Was the Ambulance Service called? (please circle) Yes / No   Name of Ambulance Officer in charge of treatment (if known) …………………….………………………………   Were the Police notified? (please circle) Yes / No   If yes by whom? ………………………………………………………………..………………………………………    Name of Police Officer in attendance ……………………….………………………………………………………   Police Station ………………………………………………………………………………………….………….……

Witnesses to accident / injury / incident (at least two required)   Name ………………….………….……………………………………………………………………………………   Address …………………………………………………………………………………………………………………    Phone Number …………………………………………………………………………………………………………   Name ……………………………………………………………………………………………………………………   Address …………………………………………………………………………………………………………………    Phone Number …………………………………………………………………………………………………………

If any significant delay in reporting this accident, injury or incident, please state reason(s)   ……………………………………………………………………………………………………………………………   ……………………………………………………………………………………………………………………………   ……………………………………………………………………………………………………………………………

Accident / injury / incident first reported to:   Name ……………………………………………………………………………………………………………………   Position within the Club …………………..……………………………………………………………………………   Address …………………………………………………………………………………………………………………    Phone Number …………………………………………………………………………………………………………   Date Reported ….…………………………………..                     Time ……………………………………………

Details of person completing this form (cannot be the injured person)   Name ……………………………………………………………………………………………………………………   Position within the Club …………………..……………………………………………………………………………   Phone Number …………………………………………………………………………………………………………   Date ….…………………………………..

                                                                                                                                                

Please send a copy of this completed form to Probus South Pacific Limited by

 

Email to [email protected]

Or

Post

Probus South Pacific Limited

PO Box 1294

Parramatta NSW 2124

On receipt of this form, a claim form will be provided to the injured person/s.  For details of the coverage provided under the National Insurance Program, please refer to the Club Administration section of Probus South Pacific website which can be accessed with your Probus Membership Card number as the login and password.

If you have any questions about this form, please contact the PSPL Team by email or phone.

 

FORM 3

MANAGEMENT COMMITTEE NOMINATION FORM

Club Name   the Combined Probus Club of Belmont Central Inc.                                                                                                                                    

 

Committee Position                                                                                                                                                         

 

Name of Nominee (print)                                                                                                           

 

Signature of Nominee                                                                                                                  

 

Proposed by (print)                                                                                                                      

 

Signature                                                                                                                                         

 

Seconded by (print)                                                                                                                      

 

Signature                                                                                                                                         

 

Completed forms to be received by Secretary by (date)                                                                                                                                                              

 Completed nomination forms must be received by the Secretary either in person, by post or by email by the date nominated above.