First name *Last name *Street name + number *Zipcode *City *Mail address *Date of birth *Mobile number *Bank account (IBAN) *Emergency number *Educational instituteStudent numberNKBV membership nummerCustomer number Sports Center (Important, this will be used for subsidy at the Sports Center) I declare that TilSAC can use my customer number from the Sports Center House rules (https://tilsac.nl/huishoudelijk-reglement/) and Privacy (https://tilsac.nl/privacybeleid/) * I hereby declare by means of my signature that I have taken knowledge of and agree with the terms and conditions of TilSAC * I authorize TilSAC to continuously debit the yearly contribution (established by the ALV) from the bank (IBAN) account mentioned above * In addition, I declare that if I participate in TilSAC activities, it will be at my own risk. Also, I declare that I have arranged a valid insurance for any risks or harm during climbing which will cover my own risks, but also cover any accident caused by myself (material, physical or mental damage). Finally, I can in no way hold the association or the board members accountable or make claims regarding any injury, damage and loss occurred during any TilSAC related events. *Contribution * Contribution academic year 2021 - 2022 (€ 22,00) Amount * € Payment method * iDEAL (+ € 0.29) Overboeking (+ € 0.45) I hereby give authorization to collect the recurring amount from my account periodically. Total € Continue to payment