www.tavistockathletics.com
APPLICATION FOR SENIOR MEMBERSHIP 2009
|
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 √ membership
required
|
|||||||||||||||||||||
|
Single Senior Membership
|
£ 50
|
|
|||||||||||||||||||
|
Family Membership (2 Adults)
|
£ 80
|
|
|||||||||||||||||||
|
Concessions
|
Coach
(Active & Qualified) / Student / 2nd Claim
|
£ 25
|
|
||||||||||||||||||
|
Total Membership Fee enclosed
|
|
||||||||||||||||||||
|
England Athletics Affiliation is included in membership. Tick box to
opt out*
|
|
||||||||||||||||||||
|
MEMBER
DETAILS |
(Please complete all sections in BLOCK CAPITALS) |
||||||||||||||||||||
|
Surname |
Forename |
DOB |
|
Gender
|
||||||||||||||||||
|
|
|
|
|
Male / Female |
||||||||||||||||||
|
Address: Inc. postcode |
|
Telephone No: |
||||||||||||||||||||
|
Mobile No: |
||||||||||||||||||||||
|
Emergency Contact Name & Tel. Number: |
||||||||||||||||||||||
|
Email: |
|
|||||||||||||||||||||
|
ADDITIONAL MEMBERS |
Please complete medical information / emergency
numbers
|
||||||||||||||||||||
|
Surname |
Forename |
DOB |
|
Gender
|
|||||||||||||||||
|
|
|
|
|
|
|||||||||||||||||
|
MEDICAL INFORMATION |
|||||||||||||||||||||
|
To help ensure your safety when
training please supply details of previous/current medical history. |
|||||||||||||||||||||
|
Does anyone above from any
illness / medical condition? |
Yes/No |
If Yes please give details |
|||||||||||||||||||
|
Are they
allergic to any drugs etc? |
Yes/No |
If Yes please give details |
|||||||||||||||||||
|
Are they currently taking medication? e.g. Drugs/Inhalers |
Yes/No |
If Yes please 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 |
|||||||||||||||||||
|
|
|||||||||||||||||||||
|
Doctors name & contact number: |
|
||||||||||||||||||||
|
Member: |
Additional Member (if
different): |
|
|||||||||||||||||||
|
|
|
|
|||||||||||||||||||
|
||||||||||||||||||||||
|
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 |
|
|
Signed |
Date |
*