Hastings and District Canoe Club

Membership form

Personal Details:

Name: ......

Male/Female: ......
Age: ......

Date of Birth: ......
Address:......
......
......

Postcode: ......
Tel (h): ......

Tel (w): ......

Tel (m): ......
E-mail: ......

Fax: ......

Please note that your contact and personal details will be kept on a computer file to facilitate proper distribution of our newsletter and other administration. Your name and phone numbers will be available to other members via HDCC website. Please let us know if you do not wish so.

Medical/ Injury Details:

Detail any medical conditions/ allergies that we should be aware of? ......

Please provide details of medication that must be administered: ......

Do you have any past or current injuries that we should be aware of? ......

If yes, please provide further details: ......

These details may need to be passed onto the coach or competent paddler in charge.

Emergency Contacts:

Name: ......

Address: ......

......

...... …….
......

Postcode: ......
Relationship: ......

Tel (m): ......
Tel (h): ......

Tel (w): ......

.

Membership Fees:
Member: / Fee: / Please tick:
Adult / £50
Students / £25
Child / £25
Social / £10
Non Bcu Adult / £4
Child / £2
Boat Storage/Hire / £0
Total / £

I have read and agree to abide by the rules and regulations of Hastings & District Canoe Club. A Copy of the Rules and Regulations are available in the clubhouse.

I am aware of the fact that it is for my own safety and that of other paddlers to declare any relevant medical conditions. I will inform the paddler in charge of the session.

I am aware that my data will be held on a computer system and that my details will be accessible as previously stated

I am aware that I need to sign a separate Parents Consent Form for each child under 18

Signed: ……………………………………… Date: …………………………… …….

For members under 18:

Parent or Guardian Name (block capital): ………………………………………………………..

Signed: ………………………………………………Date:……………………………..

BCU No / Expiry
date / Star
Awards / Coaching
Qualification / Comp
Ranking / FSRT
(expiry) / First
Aid
(expiry) / Other
Course / CRB
No

NOTE: If you are a member at the end of March 2013 you will not have to redo this form you will be signing for the duration. If however you have to change information on the form you will need to redo the form for the following year.

Ethnicity:

In order to help the club monitor its membership please will you tick one of the following boxes to identify your ethnic group/origin

A: White British Irish

Any other white background (please specify) ……………………………………

B: Mixed White & Black Caribbean White & Asian

White & Black African

Any other mixed background (please specify)……………………………………

C: Asian or Asian British Indian Pakistani Bangladeshi

Any other Asian background (please specify)……………………………………

D: Black or Black British Caribbean African

Any other Black background (Please specify)……………………………………

E: Chinese or other ethnic group Chinese

Any other (please specify)…………………………………………………………

Thank you for filling in the form