On-line Application Form - for temporary membership only
YOUR DATA- required data is marked **
EA licence number if you have one
   gender**
surname**
forenames**
date of birth**
date of application
  member type select membership information
address 1**
address 2
area of town
town/city**
county/country
postcode
code and phone**
email address
mobile
name of emergency contact** (if applicant under-16 parent or carer preferred) emergency contact notes

phone of contact**
address of contact**

PLEASE TELL US IF YOU ARE AWARE OF ANY MEDICAL CONDITIONS** or IF YOU HAVE MEDICATION**
asthma  epilepsy   diabetes   haemophilia   other (specify)
  medical information note
please give any further detail you think we should know

If an athletics club member elsewhere, please state where

DECLARATION**
important information on club rules, photography and data protection

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



Name of person submitting this form
date
I am the

click first to entries then click to send