Membership Form — Blind Sport New Zealand

AFFILIATE athlete membership form

To confirm your Affiliate Membership to Blind Sport New Zealand, please complete ALL applicable fields of the below form, and return to Blind Sport New Zealand with your Affiliation Fee (NZD$10.00).

Affiliation Fee should be deposited via bank transfer to:

Account Name: Blind Sport New Zealand Incorporated
Account Number: 03-0195-0325293-00
Reference: SURNAME, AFEE

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone

Primary Sport

Are you a member of a BSNZ Affiliated Sport?

Please provide a brief description of your sporting background

Declaration

I declare that the above information is true and correct, and that any false information supplied will result in my being removed as an affiliated athlete of Blind Sport New Zealand Incorporated, and any funding received paid back to Blind Sport New Zealand Incorporated immediately.

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