New Membership Application

Fields marked with * are compulsory

Membership type
Title *
First name *
Last name *
Birth date *
(YYYY-MM-DD)
Gender *
Identity type *
Identity number *
Home language *
Occupation *
Mobile phone number (ex: 27725551234) *
Email address *
Citizenship country *
Residency country *
Physical address *
Physical postal code *
Physical city *
Physical country *
Postal address *
Postal code *
Postal city *
Postal country *
Emergency contact name *
Emergency contact phone number (ex: 27215551234) *
Home phone number (ex: 27215551234)
Work phone number (ex: 27215551234)
Fax phone number (ex: 27215551234)
Medical aid company name
Medical aid membership number
Medical conditions
Medication in use
Medical allergies
Western Province Athletics Licence Number
Triathlon SA Membership Number
T-shirt Size
Do you accept the terms & conditions of membership? *