www.tavistockathletics.com
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APPLICATION FOR JUNIOR MEMBERSHIP 2009
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New Member / Renewal
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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
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Membership
Type (please tick √ membership
required)
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Single Junior Membership
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£ 20
per term (3
terms per year)
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Family Membership (2 Juniors)
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£ 32
per term (3
terms per year)
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England Athletics Fee is included in 1st
term membership fee.
All Junior athletes aged 11 and over who wish to compete
for the club must be affiliated.
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MEMBER DETAILS |
(Please complete all sections in BLOCK CAPITALS) |
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Surname |
Forename |
Date of Birth |
Age (At 1/04/09) |
Gender
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M / F |
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M / F |
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Address: Inc. postcode |
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Emergency Contact Name
& Tel. No: |
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Tel No: |
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Mobile: |
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Email: |
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Parent / Guardian (please
indicate) |
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MEDICAL INFORMATION |
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To help ensure your safety when
training please supply details of previous/current medical history For all Junior Members listed above. Use separate sheet if necessary. |
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Does
anyone above from any illness / medical condition? |
Yes/No |
If Yes please give details |
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Are they
allergic to any drugs etc? |
Yes/No |
If Yes please give details |
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Are they currently taking medication? e.g. Drugs/Inhalers |
Yes/No |
If Yes please give details |
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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 |
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Doctors
name & Contact number: |
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Junior Member: |
Additional Junior Member (if different): |
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I give consent for the above named child/children
to take part in coaching sessions, fitness tests, competitions and other
related activity organised by Tavistock Athletic Club or affiliated body and
for first aid and/or appropriate medical assistance to be administered to
him/her in the event of an accident or injury. I understand that neither
Tavistock Athletic Club nor any organisation providing facilities, their agents servants and employees accept any responsibility
for loss, damage or injury caused by or during attendance at any Tavistock
Athletic Club activity except where this can be shown by result of negligence
of the said parties. I understand that Tavistock Athletic Club may arrange
for photographs to be taken of its activities and consent to photographic
images of the above named child/children to be used by Tavistock Athletic
Club for promotional purposes. |
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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 |
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Signed: Parent / Guardian. |
Date |
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TAC Use Only:
Subscriptions Paid: |
Jan-Apr |
£ |
May-Aug |
£ |
Sep-Dec |
£ |
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