Membership Application submission

Membership Application form

Title:
First Name:
Last Name:
Date of Birth:
Gender: Female Male
Address 1:
Address 2:
Town/City:
County:
Post Code:
Home Phone:
Mobile Phone:
E-mail:
Please provide a valid email address or the form will appear to send but not get through. Thank you.

Emergency Contact 1:
Name:
Relationship:
Contact Number:
Emergency Contact 2:
Name:
Relationship:
Contact Number:


Current Level of Running:

Half Marathon + 10 miles 10k 5k Beginner

Membership Type (annual membership runs April-March)

Adult (including UKA affiliation)
Joining April to June £27
Joining July to September £24
Joining October to December £21
Joining January to March £18
Adult (without UKA affiliation)
Joining April to June £12
Joining July to September £9
Joining October to December £6
Joining January to March £3
Adult second claim
Joining April to June £12
Joining July to September £9
Joining October to December £6
Joining January to March £3
Junior (including UKA affiliation)
Joining anytime £15
Junior (without UKA affiliation)
Joining anytime FREE

Following submission of this form please make payment online - BACS details: NatWest | NetleyAbbeyRunners | 60-20-03 | 34660046

Declaration

I confirm that I am able to compete under UK Athletics Rules. I agree to the disclosure of my personal data for the club's administrative procedures and for my details to be registered with Run England (England Athletics) as a new club runner.

I wish to become a member of Netley Abbey Runners, and hereby agree to abide by the Code of Conduct & Constitution

A copy of the UK Athletic Rules, Code of Conduct and Constitution can be found on our Policies and Procedures Page

I confirm that I am aware that photos and videos taken at official club events may be used on the website and NAR social media accounts (e.g. Facebook and Twitter) – Please email the Club Secretary if there is an issue with this.

I have read and understood the Code of Conduct



Medical Questionaire

Yes No
Do you have a Heart Condition?
Have you experienced and chest pains when exercising / running in the past month?
Do you ever lose balance or suffer from any unexplained dizziness?
Do you ever lose consciousness or faint?
Do you have any bone or joint problem that may become worse by a change in physical activity?
Is your doctor currently prescribing and drugs for blood pressure or a heart condition?
Are you aware of any other reason why you should not exercise?

If you have answered yes to any of the above questions, please consult your doctor prior to returning your application form All medical information disclosed on this form will be used in the strictest of confidence by our Run Leaders to ensure that risk assessments can be taken to help prevent accidents and incidents during a run and to help facilitate care if a medical emergency arises. Details of the Run Leaders can be found on the website. It is important to advise the Club Secretary, Vicki Brunink secretary@netleyabbeyrunners.com, if there are further potential issues so that this information can be conveyed to the Run Leaders prior to the scheduled runs.


Ethnic Origin

White (UK)
White (European)
White (Non-European)
Bangladeshi
Black (UK)
Black (African)
Black (Caribbean)
Chinese
Indian
Pakistani
Mixed Race
Other


Digital Signature

By selecting this box you confirm the above information is accurate and that you agree for this information to be passed digitally to Netley Abbey Runners. For those affiliated athletes, your details will also be passed to England Athletics.
Name (if signing as Parent or Guardian of an applicant under 16)
Date