Elswick Harriers Athletics Club Membership

Application Form. Please scribe clearly.

Title / Gender
First Name / Last Name
Date of Birth
Address
House Number
1st Line Address
Town / City
Post Code
Contact Details
Home Tel No
Mobile Tel No
E-Mail Address
If there are any changes to your contact details, please inform the club.
Would you consider being an occasional marshal or helper at the club?
Would you consider in the future becoming a coach or coaching assistant? / Yes / No
Yes / No
Do you have any coaching experience or qualifications in athletics?If yes, please state:
*ALL APPLICANTS: It is the responsibility ofEVERY PERSONJOINING TO INFORMthe ‘club’ the assigned coach or running group leader of any pre-existing medical condition/s or medication taken. If so, please state below:
*ALL APPLICANTS to sign below(or parent / guardian if the junior is under 11).
I confirm that I am healthy to take part in training and where appropriate, conditioning activities.
To reiterate: I will duly inform the club, coach or group leader of any medication I take or any medical condition that may affect my running (or conditioning activities).
Signing (tick grey box as appropriate) / As an adult / As a parent orguardian
Signature (As an adult or as a parent or guardian) / Date
I confirm that I’m eligible to compete under UK Athletic Rules.
*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 as a list of members and to UK Athletics. (*Circle as applicable).
The club pays a fee to UK Athletics (UKA) upon completion of this form. Members will receive a unique registration number issued by UKA.

Thank you for joining us and welcome to Elswick Harriers.

Enjoy your running!