Membership Form
Surname:
Address:
State: Postcode: Home Phone:
Email:
Parent/Guardian1 Parent/Guardian2
Name:
Contact Phone:
Child 1 Name:
School:
Date of Birth : School Year:
Child 2 Name:
School:
Date of Birth : School Year:
Child 3 Name:
School:
Date of Birth : School Year:
The annual fee is $15 Individual or $20 Family.
Membership is from 1 January to 31 December.
For membership commencing after 31 July the fee is $10 Individual or $15 Family.
Please complete the form and forward together with a cheque made payable to:
ACT Junior Chess League, P.O Box 1403, Belconnen,A.C.T, 2616
Note that if you are playing rated games, other than Junior Chess League,
you must also be a member of the ACT Chess Association.
Admin Only
Year of Membership:
Payment by Cash / Cheque Receipt No: Date:
ACTJCL Inc.