| QUAKERS RUNNING CLUB | Membership | |||||||||||
| Hummersknott School, Edinburgh Drive, Darlington | Number | |||||||||||
| NEW MEMBER REGISTRATION | ||||||||||||
| Membership Fees are payable on 1st March each year. Please make Cheques payable to "Quakers Running Club" | ||||||||||||
| Please complete a separate form for each person applying for membership | ||||||||||||
| SURNAME | TELEPHONE No. | |||||||||||
| FORENAME | DATE OF BIRTH | |||||||||||
| ADDRESS | ||||||||||||
| POSTCODE | EMAIL ADDRESS | |||||||||||
| Emergency contact details | Name | Tel No. | ||||||||||
| Please tick if you are a qualified: | Coach | Level | First Aider | |||||||||
| Please circle below membership required | ||||||||||||
| 12 Months | 9 Months | 6 Months | 3 Months | |||||||||
| From March 1st | From June 1st | From Sept 1st | From Dec 1st | |||||||||
| INTERMEDIATE | (16 or 17 at 1st March) | 15.00 | 12.00 | 8.00 | 4.00 | |||||||
| SENIOR | 25.00 | 17.00 | 13.00 | 6.00 | ||||||||
| (All fees include England Athletics Race Levy) | ||||||||||||
| Have you ever been advised by a Doctor or other Medical Practitioner against taking part in any sport or physical exercise? | ||||||||||||
| Please give details of any medical condition: | ||||||||||||
| I confirm that I am eligible to compete under UK Athletics rules. I accept that my personal data will be held on a computer by the club. I agree to the disclosure of my personal data in a list of members for club purposes and to England Athletics | ||||||||||||
| SIGNATURE | DATE | |||||||||||
| Club training nights 6.30pm till 8.00pm Tuesday & Thursday evenings | More information & club news can be found on the club's noticeboard & website www.quakersrunningclub.org.uk | |||||||||||
| This form together with your fees can either be posted to: | or given on club nights to: | |||||||||||
| Membership Secretary | Dawn Bramley, Wayne Bramley, | |||||||||||
| Bielside, Carlton Village, Carlton, Stockton, TS21 1EA | Dave Thompson, Graham Park | |||||||||||
| (Please Advise Membership Secretary of any change to your details at the above address) | ||||||||||||