Over 18 Membership Regsitration – Harborough Athletic Club

Personal Details of Applicant

Forenames *

Surname *

Addresss *

Town *

Postcode *

Telephone

Mobile

Email *

Gender *

Male
Female

Date of birth *

County of birth *

Do you belong to another athletic club?

YES
NO

If Yes, which and give EA registration number

Emergency Contact Details

In case of an incident/accident, please indicate who should be contacted : -

Contact Name (e.g. Spouse/Parent) *

Emergency Contact Number *

Next of Kin *

Relationship *

Medical Information

Please detail below any important medical information that our coaches should be aware of.

Medical Information *

Do you use an inhaler or epi-pen? *

YES
NO

England Athletics has requested that all athletes who use inhalers should notify their club, and may also be asked to register their inhaler prior to competition. This is to protect genuine inhaler users. It may also be helpful to those persons who supervise your training group.

Genral Information

What events are you particularly interested in?

Do you wish to compete at the above discipline(s)?

YES
NO

Which discipline(s) would you like to compete at?

Have you any interest in coaching?

YES
NO

Have you any interest in becoming an official?

YES
NO

Do you have any relevant qualifications/skills that you feel may be useful for coaching or committee tasks?

YES
NO

Qualifications

Would you be prepared to become involved in the work of the club?

YES
NO

Occupation?

By submitting this completed form, I agree to be bound by the rules of Harborough Athletic Club. *

Agreed

The information you provide will be forwarded to UK Athletics for competition purposes. By submitting this form you are confirming you have read and accept the clubs data protection policy.
Committee members may contact you from time to time by e-mail and phone to advise of activities arranged by the club.