MEMBERSHIP TYPE (Please put an ‘X’ as appropriate)

New Member / Renewing Member / Second Claim / ApprovedVolunteer
Senior
Track and Field / Junior/Student
Track and Field / EA NUMBER / Coaching Group

ATHLETE DETAILS (please complete all boxes)

First Name / Last Name
Address
Postcode / Country of Birth
Telephone Number / Mobile Number
(if over 16 yrs of age)
Gender / Email address
(if over 16 yrs of age)
Date of Birth / Age
(as at 31 August 2017)

PARENT / CARER DETAILS (If under 16 years of age, please ask your parent/carer to compete the following section)

First Name / Last Name
Address
Postcode / Email address
Telephone Number / Mobile Number

MEDICAL INFORMATION- Please detail below any important medical information that our coaches/junior coordinator should be aware of (e.g. epilepsy, asthma, diabetes, allergies etc.) Please do not leave blank – if there is no information please write ‘None’.

EMERGENCY CONTACT DETAILS Please insert the information below to indicate the person who should be contacted in event of an incident/accident.

Emergency Contact One – Name
Emergency Contact One – Number
Emergency Contact Two – Name
Emergency Contact Two – Number

It may be essential at some time for authorised persons acting on behalf of the club to have the necessary authority to obtain urgent treatment which may be required whilst at representative club competition or training. Please sign below to give your consent to emergency treatment being given to the named athlete on this form by trained personnel.

Signature
Print Name

ATHLETE AGREEMENT(Athlete and Parent/Carer to complete if athlete under 18 yrs of age)

By returning this completed form, I agree to:

  • Fully participate in the activities of the club including being available for competition
  • Read and abide by the club code of conduct* for athletes whenever I am present at club activities or competitions
  • Being filmed or photographed for coaching or marketing purposes
  • To my personal details being held on the England Athletics/Club Database for Club use only

* Code of Conduct is available on the club website:

Athlete Signature
Print Name
Parent Signature
(if under 18yrs of age)
Print Name


PAYMENTS

Cheque
Please make cheques payable to NDAC. Please indicate name of athlete/athletes on reverse of cheque.
Cash
Please deliver cash payments to the club house onTuesday and Thursday evenings from 6.15pm.

PARENTAL / CARER AGREEMENT (to be completed if athlete under 18 years of age) - By returning this completed form, I give my consent: (please delete as appropriate)

  1. To the named athlete taking part in the activities of the club. Yes / No
  2. To read and abide by the club code of conduct whenever I am present at club activities or competition. Yes / No
  3. To assist the club on a voluntary basis including helping at 3 club events per year.Yes / No
  4. Being filmed or photographed for coaching or marketing purposes. Yes / No
  5. To my personal details being held on the Club Database for Club use only. Yes / No

Signature / Print
Name