Pendle Athletics Club – Application for Membership
Membership is open to all irrespective of gender, ethnic origin, religion or ability.
I wish to apply for membership of Pendle Athletics Club. I am amateur according to UK Athletics rules.
Membership: (please tick) Senior (£24.00) ¨ Junior (£18.00) ¨ Young Athlete (£10.00) ¨ Family (£45.00) ¨
For Senior and Junior members £5 of the fee is for registration to England Athletics.
Please return this completed form along with your payment (cheques/postal orders made payable to Pendle AC).
Title: ______Forename(s): ______Surname: ______
Gender (please tick): Male ¨ Female ¨
Address 1: ______
Address 2: ______
Town: ______
County: ______
Postcode: ______
Tel: (______)______
Mob: (______)______
Email: ______@______
Place of Birth: ______Date of Birth: ____/____/____
School ------
Disability – The Disability Discrimination Act 1995 defines a disabled person as anyone with “a physical or mental impairment which has a substantial and long term adverse effect on his/her ability to carry out normal day-to-day activities”.
Do you consider yourself to have a disability: Yes ¨ No ¨
If yes, what is the nature of your disability?
Visual impairment [ ] Hearing impairment [ ] Physical disability [ ] Learning Disability [ ] Multiple Disability [ ] Other [ ]
Medical Conditions – Athletics is a demanding sport and it is essential that coaches/team managers are made aware of any illness or disability that athletes under their instruction and care may suffer. Please complete the following details in your/your child’s interest. The information given will be kept in the strictest confidence. Where there is concern the club may request that you seek medical advice before starting to train.
Do you suffer from: Heart/Lung defect [ ] Diabetes [ ] Epilepsy [ ] Asthma [ ] A condition that affects the bones/muscles [ ]
Are you taking any form of medication or have you suffered a disease or injury that may affect your ability to train/compete: yes/no
If yes please give details:
Emergency Contact Name: ______
Emergency Contact Number: (______)______
Disciplines in which you expect to participate:
Track & Field [ ] X country [ ] Hill & Fell [ ] Road Running [ ] Race Walking [ ] Social [ ]
Volunteer Role – The club is always thankful for any support that members can offer. Please indicate if you would be willing to help in any of the following areas (training can be provided): Track/Field/Race Official [ ] Administration [ ] Coaching [ ] Social [ ]
Photos: Photos of athletes could be used from time to time to publicise the club, do you have any objections to this: Yes/No
Signed (Parent/Guardian - if under 18): ______
Date: ______/______/______
I confirm that I am eligible to compete under UKA rules. I *accept/*do not accept that my personal data will be held on a computer by the club and occasionally used to keep me informed of athletics events/activities. I *agree/*do not agree to the disclosure of my personal data in a registration list to England Athletics (delete as appropriate). I agree to conform and be bound by the rules and observe the Code of Conduct and policies of Pendle AC.