| First Name(s) |
Title |
|
| Last Name |
Gender |
|
| Address 1 |
Date of Birth |
|
| Address 2 |
Ethnic Origin |
|
| Town |
|
|
| County |
|
|
| Post Code |
|
|
| County of birth |
|
|
Name and Address
Contact
| Home phone |
|
Mobile phone |
|
| Work phone |
|
Fax |
|
| e-mail |
|
|
|
| 2nd Contact Name |
|
|
|
| Address |
| |
| Telephone no. |
| Known allergies |
| Medication |
Membership of Other Clubs
| Status, i.e. 1st/2nd Claim |
Date of Resignation from Previous Club |
Tick Disciplines in Which You Expect to Participate
| Fell and hill |
|
| Road |
|
| Running track and field |
|
| Cross country |
|
I Confirm that I am eligible to compete under UK Athletics Rule. I *accept /
* do not accept that my Personal data will be held on a computer by the club. I *agree / * do not agree to the disclosure of my personal data in a list of members and to the North of England AA.
(*Delete as applicable).
I have seen and read the risk assessments for training sessions.
Signed
.. Date
.
Parent/Guardian if under 18
.
Annual membership fee due 1st of January: Senior £16.00, Juniors 11 to 18 £6.00, Juniors U/11 free, second claim members £8.00, Family Membership £32.00 Cheques should be made payable to: NEWTON AYCLIFFE A/C
Please download, complete and e-mail to Michael.Beadle@ineos.com
or print off and hand to Mick at a training session
NEWTON AYCLIFFE ATHLETICS CLUB MEMBERSHIP FORM