TAVISTOCK ATHLETIC CLUB

APPLICATION FOR SENIOR MEMBERSHIP 2008

New Member / Renewal

Tavistock Athletic Club is an athlete-centred, friendly club and is open to all members of the community. The Club is committed to a policy of Equal Opportunities.

Membership Type (please tick ü membership required)

Single Senior Membership		£ 35
Family Membership (2 Adults)		£ 60
Each additional family member		£ 30
Concessionary membership	Coaching (Active & Qualified)	£ 17.50
	Student / 2^nd Claim	£ 17.50
Total Membership Fee enclosed		£

MEMBER DETAILS

(Please complete all sections in BLOCK CAPITALS)

Surname

Forename

DOB

COUNTY of Birth

Gender

Male / Female

Address:

Inc. postcode

Telephone No:

Mobile No:

Emergency contact Name & Tel. Number:

Email:

MEDICAL INFORMATION

Do you suffer from any illness / medical condition?

Yes / No

If yes give details

Are you allergic to any drugs etc?

Yes / No

If yes give details

If surgery or treatment (including a blood transfusion) were required for any of the above members, do you give your consent for a club official to give consent on your behalf if asked by a Member of the Medical profession?

Yes / No

If No please state reasons

Disability - If you have a disability please indicate below the nature of your disability.

ADDITIONAL MEMBERS	Please detail any medical information / emergency numbers not recorded above
Surname		Forename		DOB	COUNTY of Birth	Gender
1.
MEDICAL:			EMERGENCY:
2.
MEDICAL:			EMERGENCY:
3.
MEDICAL:			EMERGENCY:

CLUB T-SHIRTS.

If you have NOT received a Club T-shirt in the past, please indicate size

XS

S

M

L

XL

I agree that my personal data will be held on a club database. I agree to the disclosure of this personal data in a list of club members to UK Athletics. I have read the athletes code of conduct which is on the club website www.tavistockathletics.com
Signed	Date