KILBARCHAN
AMATEUR ATHLETIC CLUB
APPLICATION FOR MEMBERSHIP
FULL
NAME________________________________TELEPHONE_________________DATE OF
BIRTH______________
ADDRESS_______________________________________POST
CODE _____________e-mail _______________________
I wish to be enrolled as
a member and I agree to comply with the constitution and rules. I also agree
that the club cannot accept responsibility for any loss, damage or injury
sustained while taking part
in club activities.
SIGNATURE____________________________________________________________DATE_______________________
PLEASE GIVE DETAILS OF ANY
MEDICAL CONDITION___________________________________________ ______
____________________________________________________________________________________________________
HAVE YOU HAD A TETANUS
INJECTION IN THE LAST FIVE YEARS?
YES/NO_________________
HAVE YOU EVER BEEN A MEMBER
OF ANY OTHER ATHLETIC CLUB? IF SO, GIVE
DETAILS, INCLUDING CLUB NAME AND EVIDENCE OF WRITTEN CLEARANCE FROM THAT CLUB IF CHANGING
FIRST CLAIM.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
PLEASE INDICATE FIRST
CLAIM______________________________________________________________________
APPLICATION PROPOSED
BY__________________________SECONDED BY_________________________________
NB. FOR APPLICANTS UNDER
16, PARENT/GUARDIAN MUST SIGN THE UNDERNOTED...………….
I agree to my son/daughter/ward, named
above, receiving any medical treatment, including anaesthetic, as considered
necessary by medical authorities present. I also agree to my son/daughter/ward
participating in doping control procedures if selected and providing a urine
sample, under observation, for analysis at an accredited laboratory, this
consent being a requirement of the Scottish Athletics Ltd (SAL).
SIGNATURE_____________________________NAME__________________________________DATE______________
EMERGENCY CONTACT
NAME___________________________________TELEPHONE________________________
APPLICATION RECEIVED
BY_______________________APPROVED BY COMMITTEE_______________________
PLEASE NOTE THAT
APPROPRIATE SUBSCRIPTION MUST ACCOMPANY APPLICATION.
THIS COMPLETED FORM WILL BE
RETAINED BY THE CLUB, AS REQUIRED BY SCOTTISH ATHLETICS LTD..
PLEASE ADVISE
PROMPTLY OF ANY CHANGE OF CIRCUMSTANCE.
Form approved 3.11.97