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Rotherham
Harriers & AC
Application Form- for Membership stated |
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YOUR DATA- required data is marked ** |
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OTHER CLUBS |
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EA licence number if you have one |
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Unless you have specified 'temporary member' or
'second claim member', this is an application for first-claim membership |
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Male |
Female |
gender**- tick which |
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If you
are or were recently a member of another Athletics Club please state which |
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surname** |
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forenames** |
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Have you resigned from that club? |
Yes____ No_____
If yes, state date |
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dd-mm-yyyy |
date of birth** |
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Has the
club acknowledged your resignation?
Yes______ No______ |
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dd-mm-yyyy |
date of application** |
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type of
membership full____ family___ junior___
associate___
second-claim___ temporary___ |
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VOLUNTARY
INFORMATION: EVENTS I AM INTERESTED IN |
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address 1** |
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Track general |
Field jumps |
Bi/du/triathlon |
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address 2 |
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Track sprints/hdls |
Cross-country |
Other: |
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area of town |
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Track midd/long distance |
Road events |
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town/city** |
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Field throws |
Trail/fell |
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county/country |
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HELPING THE CLUB:
can you help in any of these capacities? |
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postcode |
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Qualified coach |
First-aid |
Website |
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your (code &) phone** |
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Help with coaching |
General
assistance |
Contacts-schools |
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email address |
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Qualified official |
General help |
Contacts-college |
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mobile |
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Help with events |
Newsletter |
Contacts-other |
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name of emergency contact** |
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(if applicant under-16 parent or carer
preferred) |
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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 |
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if same
as above |
phone
of contact** |
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tick here |
address of contact** |
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MEDICAL INFORMATION / MEDICATION |
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Do you suffer from any of the following ? |
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asthma |
epilepsy |
diabetes |
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haemophilia |
other/s- please
specify below |
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PERSON SUBMITTING THIS FORM- |
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other or medication please give any further detail you think we should know |
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Name of person |
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Signature of person |
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DISABILITY INFORMATION |
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Please state your relationship to the athlete
applying |
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If you consider yourself to have a disability
please tick |
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I am the athlete |
Parent of |
Carer of |
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Visual
impairment |
Hearing impairment |
Physical disability |
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(optional) any RHAC member
supporting application |
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Learning
disability |
Multiple disability |
Other (please
specify) |
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please give any further detail you think we
should know |
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continue here or overleaf if necessary… |
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send
to: Steve Gaines, 92 Bawtry Road, Bessacarr , Doncaster, DN4 7BQ Tel: 01302 538408 |
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