Membership Application

Name of 1st Member*
First Name Surname
Date of Birth*
Day Month Year
Name of 2nd Member
First Name Surname
Date of Birth
Day Month Year
Additional Family Members Names and DOB

Address*

Street Address
Street Address Line 2
City	County
Post Code	Country

Telephone*
- Area Code Phone Number
Mobile
- Area Code Phone Number
E-mail*
Annual Membership (ProRata until Dec 31st 2013*

Adult over 16s £16.50 Junior under 16s £9 Couple (living at same address) £27.50 Family (2 adults, all children at same address) £35.50
If any applicants are British Cycling members please add membership numbers here
Ethnicity

White British Irish Black / Carribean African Black British Asian Indian Pakistani Asian British Bangladeshi Other
Religion

Christian Buddhist Hindu Jewish Muslim Sikh Other Undisclosed No Religion
Disability Information

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 or her ability to carry out normal day-to-day activities.’

Please indicate below if you consider yourself to have a disability?

If yes, what is the nature of your disability?
Do you consider yourself to have a disability?

Yes No
Nature of Disability
Medical Information

Please detail below any important medical information that our coaches/club should be aware of (e.g. epilepsy, asthma, diabetes, a recent injury, etc). Medical condition(s) and recommended treatment/actions to be taken if symptoms appear: If you have any concerns about your child participating in any form of physical activity then please consult your GP before giving permission for your child to take part in cycling activity sessions.
Medical Information
Contact in case of emergency*
First Name Last Name
Emergency contact number*
- Area Code Phone Number
It is necessary to obtain consent for your child to take part in the Go-Ride activity. If you wish your son /daughter to participate then please read the following information, complete the form below and sign the Parental Consent Notice. All Coaches are trained British Cycling Coaches that have received training in Safeguarding and Protecting Children, and have been checked and cleared through the Criminal Records Bureau. Any information provided about your child will be kept confidential and secure. It will only be used for the purpose of contacting you or your child regarding future club and Go-Ride events. With your permission the club may also take photographs/video footage during Go-Ride activity. These images could be used in coaching resources, placed on the club’s website, or for general publicity purposes. If you are happy for photographs/video footage of your child to be taken and used in this way, could you please tick the appropriate box below.
By submitting this completed form, I agree to the child named above taking part in the activities of the club

I understand that I will be kept informed of these activities - for example timing andtransport details

I understand that in the event of any injury or illness all reasonable steps will be taken to contact me, and to deal with that injury/illness appropriately

A cycling helmet must be worn at all time during activity.

Any participants who persistently misbehave or put others in danger will be asked to leave the activity and will not be allowed to continue.
Name of Parent / Carer
First Name Last Name
Consent

I am happy for photo/video footage to be taken of my child
Declaration*

I confirm that I have read and accept the terms on this form and the Hadleigh MTB Code of Conduct
Select Payment Amount*
Adult Membership £16.50 GBP
Junior Membership £9.00 GBP
Couple Membership £27.50 GBP
Family Membership £35.50 GBP
Prove you are a human (or very talented chimp)*
Should be Empty:

Membership Application Form