APPLICATION FOR NEW MEMBERSHIP OR RENEWAL (1st April 2016 - 31st March 2017)

Title: / First Name:
Surname:
Address:
Postcode:
Home Tel No.: / Mobile No.:
Email Address:
Date of Birth:
If a member of another UK Affiliated Athletics Club enter club name here:

ANNUAL SUBSCRIPTION CHARGES

Cheques payable to ‘East Cornwall Harriers’

BACs details available on request from Treasurer Tess Mason - Email:

MEMBERSHIP / NEW MEMBERS* OR RENEWING MEMBERS BEFORE JUNE 1ST 2016 / RENEWING MEMBER JUNE 1ST 2016 ONWARDS**
Senior (17+) / £15 / £20
OAP’s / Unemployed / Students (17+) / £5 / £10
Family Membership (up to 2 adults plus children under 17) / £35
Please complete a form for each family member / £45 + £2 per Child
Please complete a form for each family member
Under 17s/ Associated Members (non-running) /Temporary / £10 / Under 17s - £12
Associated /Temporary -£15
Second Claim / £5 / £10
Life Members / NIL

*New Members joining after 31st December 2016 your membership will carry forward to April 2018.

**Renewing Members joining from 1st June 2016 onwards will incur an additional late renewal charge. £5 for adults, £2 for juniors.

ENGLAND ATHLETICS MEMBERSHIP (In Addition to ECH Membership)

o  If you wish to be registered with EA please tick here and add £14 to your subscription. You will need to be an EA member for longer than 6 months to be eligible for an ECH club place for the London Marathon. (For family membership please add £14 per person wishing to have an EA membership).

PLEASE COMPLETE BELOW & SEND APPLICATIONS TO:

Mr. Marc Doyle, 2 Ferndale Terrace, Liskeard, PL14 6DT. Email:

(Completed membership forms can also be given to the Head Coach or a committee member.)

Membership Type (e.g. Senior + EA):
Amount Enclosed/Paid:

I consent to the membership details as given above being held on a computer database for ECH purposes only.

Signed*:
Print Name:
* Parent or Guardian, if under 18. / Date:
MEDICAL INFORMATION
Please detail below any important medical information that our coaches should be aware of (e.g. epilepsy, asthma, diabetes, etc).
EMERGENCY CONTACT DETAILS
Please insert the information below to the person(s) who should be contacted in case of an incident or
accident.
Contact Name(s):
Emergency Contact Number(s):

JUNIOR MEMBERS

PLEASE CAREFULLY READ THE JUNIOR MEMBER INFORMATION, TRAINING DISCLAIMER AND JUNIOR CODE OF CONDUCT BEFORE SIGNING.

JUNIOR MEMBERS TRAINING DISCLAIMER
I accept that the training of my child, if attending Tuesday evening sessions, during the winter months will entail training on the public highway. I further accept that training on the public highway cannot be made
free from the risks of injury or accident including those caused by collision with vehicles. I am content that
East Cornwall Harriers will take all reasonable means to minimise risk of injury/accident, including the use of risk-assessed training venues only (the venues can be viewed on the club website:eastcornwallharriers.com) and all sessions being supervised by the appropriate number of UK Athletics licensed coaches. I accept that East Cornwall Harriers and its coaches, officials and members shall not be held responsible for any injuries,
loss or damage sustained by my child howsoever caused during the training sessions or participation in any competitive events.
Please note that only juniors between Year 7 (1st year secondary school) and 16 years of age inclusive will be permitted to train on Tuesdays when junior training sessions take place on the public pavements/roads during the winter months (approx. 1st Oct to 31st March).
PHOTOGRAPHY DISCLAIMER
Please note whilst as a club we do not authorise or condone the taking of photographs, images or videos of children/young athletes (except photographs by bona fide press photographers)it is possible that photography may be in use at junior running events.
JUNIOR CODE OF CONDUCT
A copy of the Junior Code of Conduct can be read on the club website. Please confirm by signing below that you have read and agree to abide by its contents. To be signed by child and parent/guardian.

I confirm that I the junior member and the consenting parent or guardian have read and understood the information above.

Parent/Guardian Signature:
Print Name in Full: / Date:
Junior Signature:
Print Name in Full: / Date:

Please continue to page 2 of the membership form.