EAST END ROAD RUNNERS MEMBERSHIP FORM 2018 /2019 [NEW MEMBERS]

Club Season runs from 1st April 2018 to 31st March 2019

Name:______DoB (over 18 only): ______Gender: M/F

Address:______

______Post Code:______

Email:______Contact Number:______

Emergency Contact Name & Number: ______

To which of these ethnic groups do you belong? (Please tick one only)[required by UK Athletics]

White
British
Irish
White other / Asian
Indian
Pakistani
Bangladeshi
Chinese
Other Asian origin / Black
Caribbean
African
Black British
Black other / Mixed
White & Black Caribbean
White & Black African
White & Asian
Any other mixed background
Other ethnic group

Do you consider yourself to have any type of disability or access needs? Yes/No

If yes, please give further details:

______

Do you have any other medical conditions you would like the EERR coaches to be aware of? Yes/No

Ifyes, please give further details: ______

Type of membership and payment : (Please tick as appropriate).

First Claim athletics club. £22 annual membership fee

Second Claim member. £15 annual membership fee. I am a first claim member of:______

Please pay either cash to Dave Elsom or transfer to the East End Road Runners’ Account.

Sort Code 20-67-90, Account Number 30467820

How did you hear about the club (if via a current member please give their name)?______

I participate in Club Sessions at my own risk. I am sufficiently responsible and competent to assume full responsibility for my own safety, alongside the supervision of a coach.

I will abide by the Club’s Code of Conduct – as displayed on the website and in the clubhouse.

Signed:______Date:______

DATA: When you become a member of, or renew your membership with, EERR your data will be stored in a Excel spreadsheet which will be available to the Club Chairman, Treasurer, Membership Secretary, Welfare Officers, Coaches and Leaders. You will also automatically be registered as a member of England Athletics. We will provide England Athletics with your personal data which they will use to enable access to an online portal for you (called myAthletics). England Athletics will contact you to invite you to sign into and update your MyAthletics portal (which, amongst other things, allows you to set and amend your privacy settings). If you have any questions about the continuing privacy of your personal data when it is shared with England Athletics, please contact . If you have any questions about the continuing privacy of your personal data at EERR please contact and/.

IMAGE:As a member of EERR I consent to my image being used on the club website and in the club’s promotional material.