Rotherham Harriers & AC           Application Form- for Temporary Membership Only
	YOUR DATA- required data is marked **			MEDICAL INFORMATION / MEDICATION
				Do you suffer from any of the following ?
		EA licence number if you have one		asthma	epilepsy	diabetes
	Male	Female	gender**- tick which	haemophilia	other/s- please specify below
			surname**	other or medication
			forenames**
	dd-mm-yyyy	date of birth**		please give any further detail you think we should know
	dd-mm-yyyy	date of application**		IF YOU ARE A CLUB MEMBER SOMEWHERE ALREADY
	------temporary------	type of membership		please tell us where:
			address 1**
			address 2	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 agree to abide by the club rules  The information I have stated above is correct as far as I am aware
			area of town
			town/city**
			county/country
			postcode
			your (code &) phone**
			email address
			mobile
			name of emergency contact**		Name of person submitting this form
	(if applicant under-16 parent or carer preferred)				Signature of person submitting this form
	if same as above		phone of contact**	Please specify your relationship to the athlete applying
	tick here		address of contact**	I am the athlete	Parent of	Carer of