Membership Form - 2017
Fees
Annual subscriptions are due in the month of January.
Fees are to be paid to Jo Beddow (Treasurer) within two weeks of first attendance.
Enquiries to Jo Beddow (tel: 07824905266), email:
Seniors: £25.00 Under 16’s: £13.00
Senior applicants wishing to join in the latter part of the year will have that year’s subscription set by the committee.The club encourages participation in track & field events, cross country, fell races and road races. Membership is open to all groups of the community.
Personal Details
First name………………………………… Surname……………………………………….
Date of Birth………………………………..
Gender: Male / Female
Contact Details
Address……………………………………………………………………………………………
………………………………………………………………………………………………………
…………………………………………………………Postcode…….…………………………
Home telephone……………………………………
Mobile………………………………..…….
Email address…………………………………………………………………………………….
Please turn the page
Medical details
Please detail any medical conditions that we should be aware of in case of emergency (eg. Asthma):
………………………………………………………………………………………………………
………………………………………………………………………………………………………
Photographic Permissions
Hartlepool Burn Road Harriers & AC recognises the need to ensure the safety and welfare of all young people in sport. In accordance with our child protection policy we will not permit photographs, video or other images of young people to be taken without the consent of the parents/guardians of the children. Any photographs/videos taken will be used in the gallery on the club website or for training purposes. Also, from time to time such photographs may be used in local press to accompany news articles. In such cases, Hartlepool Burn Road Harriers & AC will pass on these photographs with the highest regards to the security of images.
If this form is being completed for the membership of someone that is under 18, please tick one option below:
I DO consent to representatives of Hartlepool Burn Road Harriers & AC photographing or videoing my child’s involvement in athletics for use in the above situations:
I DO NOT consent to photographs/videos for use in the above situations:
As part of your membership to Hartlepool Burn Road Harriers, you will also
become affiliated with England Athletics. Data provided on this form will be stored on a database managed on behalf of England Athletics by Athletics Services. Personal contact information will be used to send a competition license / membership card and seek appropriate data clearances.
Hartlepool Burn Road Harriers will maintain the information provided on this form in their own database and a copy of this form will be retained. Your personal data will be kept secure at all times in line with the Data Protection Act. Your data will not be passed on to any third parties with the exception of England Athletics.
Declaration
I confirm that I am eligible to compete under UK Athletics rule. I agree to my details being stored on a database held by Hartlepool Burn Road Harriers &AC and to the disclosure of my details to England Athletics.
Signature Date………………………………………………………………….…………………………………….
(IF SENDING ELECTRONICALLY, YOUR TYPED NAME WILL BE ACCEPTED AS A SIGNED DECLARATION)
First / Second Claim (please delete) **
Fee enclosed £…………………..
** Second claim members are first affiliated to another athleticsclub, if so please name club…………………………………………………………………………………………………………………….………………