MEMBERSHIPAPPLICATION/RENEWAL

1April2017to 31March2018

Tracy Stevens, 46 Melton Road, Wymondham, Norfolk, NR18 0DB

Please tick your chosen category of WAC membership:
Single membership
(after 4September 2017)
£21* / 2nd Claim member
(after 4September 2017)
£10
 / 

*The club registers all members withEngland Athletics. £14of this amount is paid to England Athletics.

Please complete in BLOCK LETTERS:

SURNAME / FIRST NAME / MALE/FEMALE
ADDRESS
POSTCODE
Date of birth
Home telephone / Mobile Telephone
Email
Contact name & telephone in case of emergency
First Claim UKA Yes/No
Or ARC affiliated club if not WAC / England Athletics No (if known):

Wymondham AC is run entirely by its members, none of whom receive any form of payment from the Club for their time, whether as a coach, committee member, marshal, race organiser or in any other capacity. We therefore need plenty of help from members to keep the club functioning effectively.

Please consider helping in one or more of the following ways:

  • At the Wymondham AC 10K race on 1 January 2018, when we will need lots of marshals.
  • At the Wymondham AC 20 mile race on 25 March 2018, when we will again need lots of marshals.
  • Assisting with coaching.
  • Assisting with teas on a few Club Night Mondays each year.

Please go to the next page ….

Declaration: I agree to abide by the rules and Constitution of Wymondham Athletics Club (“WAC”) and the rules of those bodies regulating the sport of athletics to which I and/or WAC are affiliated. I am not under 18.

Save in respect of death or personal injury arising from negligence (or any other liability that may not legally be excluded or limited), I:

(a)agree thatWAC will not be liable to me for any direct or indirect loss, damage, injury or death incurred or suffered by me;

(b)waive all and any claims, past present and future,that I may have against WAC and any of it officers, committee members or coaches;

(c) waive all and any claims, past present and future,that I may have against any WAC member involved in any activity organised by WAC or organised principally for WAC members and/or their guests;

(d) waive all and any claims, past present and future, against any person assisting WACor any of its members, officers or volunteers, in the planning, organising, preparation for, conduct of, or clearing up from activities (including running and social activities, whether or not involving running) organised on behalf of WAC or principally for its members arising from any WAC activity,

and acknowledge that all committee members, coaches and volunteers are acting on a voluntary basis in that respect.

I agree that WACmayuse the personal data that I provide to it (including sensitive personal data), whether on this form or otherwise from time to time, and pictures of me,for administrative purposes and to promote, publicise and report on WAC and athletics(including on its website and via social media and to WAC members or others) and that WAC may provide such data to its officers and members, to any insurer or prospective insurer, toany athletics club or governing or co-ordinating body (including Athletics Norfolk, England Athletics UK Athletics andother bodies associated with any of them and/or with the sport of athletics), to any other athletics club and to the organiser of any event related to athletics(including any race which I enter and/or in which I participate or with which I assist). I further agree that for such purposes WAC may transfer my personal date outside the European Economic Area, including to the USA.

I acknowledge that if I take part in any race organised by WAC (a) it may include my personal data in lists of entries and results which WAC may make publicly available on any website or by any other means and (b) that I will provide a non-member to help in my place in connection with the staging of the event.

Signature / Date

Please tick one of the following:

A cheque payable to Wymondham Athletic Club accompanies this form / A payment in cash accompanies this form / I have made a bank transfer to the account detailed below (please use your name or UKA number as a reference)
Bank: / Lloyds Bank plc / FOR USE OF MEMBERSHIP SECRETARY ONLY
Sort code: / 30-63-94 / Date form received
Account number: / 34928660 / Payment method
Account name / Wymondham Athletic Club / Payment amount / £
Date payment received
Balance owing / £
Date balance owing received
Date payment banked
Paying in reference
Date UKA database updated
Date UKA affiliated
UKA Fee amount
Date UKA fee paid
Date database updated
Date mailing list updated
Date payment acknowledged to member
Date membership confirmed to member