Rotherham Harriers & AC           Application Form- for Membership stated    
  YOUR DATA- required data is marked ** OTHER CLUBS  
    EA licence number if you have one Unless you have specified 'temporary member' or 'second claim member', this is an application for first-claim membership  
  Male Female gender**- tick which If you are or were recently a member of another Athletics Club please state which  
    surname**    
    forenames** Have you resigned from that club? Yes____  No_____  If yes, state date    
  dd-mm-yyyy date of birth** Has the club acknowledged your resignation?   Yes______     No______  
  dd-mm-yyyy date of application**  
  type of membership  full____  family___    junior___    associate___   second-claim___    temporary___ VOLUNTARY INFORMATION: EVENTS I AM INTERESTED IN  
    address 1** Track general Field jumps Bi/du/triathlon  
    address 2 Track sprints/hdls Cross-country Other:  
    area of town Track midd/long distance Road events    
    town/city** Field throws Trail/fell    
    county/country HELPING THE CLUB: can you help in any of these capacities?  
    postcode Qualified coach First-aid Website  
    your (code &) phone** Help with coaching General assistance Contacts-schools  
    email address Qualified official General help Contacts-college  
    mobile Help with events Newsletter Contacts-other  
    name of emergency contact**  
  (if applicant under-16 parent or carer preferred)  DECLARATION**
 This is my application for membership as detailed above. I confirm that:-

 I have read the important information on club rules, photography and data protection, and the medical information note
 I understand and accept that authorised photographers may be used to take pictures of me/my child for club promotional purposes
 I understand that my personal data will be held securely by the club and will be used for club administration only
 I am eligible to compete under UK Athletics Rules
 I/we agree to abide by the club rules and issued codes of conduct
 The information I have stated above is correct as far as I am aware
 
  if same as above phone of contact**  
  tick here address of contact**  
  MEDICAL INFORMATION / MEDICATION  
  Do you suffer from any of the following ?  
  asthma epilepsy diabetes  
  haemophilia other/s- please specify below   PERSON SUBMITTING THIS FORM-  
  other or medication  please give any further detail you think we should know   Name of person  
    Signature of person  
  DISABILITY INFORMATION Please state your relationship to the athlete applying  
  If you consider yourself to have a disability please tick I am the athlete Parent of Carer of  
  Visual impairment     Hearing impairment     Physical disability  (optional) any RHAC member supporting application    
  Learning disability      Multiple disability      Other (please specify)    
  please give any further detail you think we should know continue here or overleaf if necessary…  
  send to: Steve Gaines, 92 Bawtry Road, Bessacarr , Doncaster, DN4 7BQ  Tel: 01302 538408