Email
Title (Mr, Mrs, Miss, Ms, Dr, etc)
First Name
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Last Name
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Address
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Suburb
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State / Territory
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QLD NSW ACT VIC TAS SA NT WA
Post Code
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Phone
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Emergency contact name
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Emergency contact phone
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ADAA Membership Number (if applicable)
Dates of Class Attendance
Number of Dogs on Membership
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1 2 3 4 0 Currently Dogless 🙁 (Please input "nil" in fields below)
Dog #1 Name
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Dog #1 Breed
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Dog #1 DOB
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Dog #2 Name
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Dog #2 Breed
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Dog #2 DOB
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Dog #3 Name
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Dog #3 Breed
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Dog #3 DOB
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Dog #4 Name
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Dog #4 Breed
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Dog #4 DOB
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Payment Method
Direct Bank Deposit - Payment Details will be sent in confirmation email Cheque/Money Order - Payable to Agility Dog Club of Queensland Inc.
Membership Terms and Conditions
I/We hereby apply for membership to the Agility Dog Club of Queensland Inc. (ADCQ). In the event of membership admission, I/We agree to be bound by the Rules and By-Laws of the Club for the time being in force.
I/We declare that none of the dogs currently registered in my name with ADCQ are (in full or part) an American Pit Bull Terrier, Japanese Tosa, Argentine Fighting Dog, Brazilian Fighting Dog and/or any other breed which may be deemed as a restricted dog. Nor are any of them individual dogs(s) which have been deemed as dangerous dogs as defined in the Companion Animal Act 1988 (NSW) and/or defined in any other State, Territory or the Commonwealth of Australia equivalent Act.
I/We declare that none of the dogs currently registered in my name with ADCQ have been involved in any incidents that may affect my membership with ADCQ. This may include, but not be limited to, incidents that have been reported to another organisation, local council etc.
I/We hereby grant permission to ADCQ and its representatives to take photographs or videos of me and to make recordings of my voice at the dog training/competition activities conducted by ADCQ. I further grant to ADCQ and their representatives the right to reproduce, use, exhibit, display, broadcast and distribute and create derivative works of these images and recordings in any media now known or later developed. I acknowledge that ADCQ owns all rights to the images and recordings. I hereby waive any right to inspect or approve the use of the images or recordings or of any written copy. I further waive all moral rights. I also waive any right to royalties or other compensation arising from or related to the use of the images, recordings, or materials. I hereby release, defend, indemnify and hold harmless ADCQ from and against any claims, damages or liability arising from or related to the use of the images, recordings or materials, including but not limited to claims of defamation, invasion of privacy, or rights of publicity or copyright infringement, or any misuse, distortion, blurring, alteration, optical illusion or use in composite form that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution.
If you are human, leave this field blank.