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Tick as appropriate
Renewal
Salary Ded
Annual sub
Other
Spouse
Student
Quarterly Tkt
Memb no.
At the University Hospital of Wales, Heath Park, Cardiff CF14 4XW
APPLICATION FOR MEMBERSHIP
To: The Recreation Organiser,
I wish to be enrolled as a Member of the Cardiff Medical Centre Sports & Social Club and agree to abide by the rules
appertaining thereto.
00/0 0/00
Date of Birth
Prof/Dr/Mr/Mrs/Miss/Ms (please specify)
Surname
Male
Female
Forename(s)
If you don’t wish to give your date of
birth, please let us know which age
group you and your family are you in
18-30
years
Local Address
31-45
years
45-60
years
60+
years
8-13
years
13–16
years
16+
years
Dependants
Post code
Telephone (home)
0-8 years
Mobile
E mail
(home)
Hospital
Any data supplied by you on this
form will be processed in
accordance with Data Protection
Act requirements and in supplying it
you consent to the Club processing
the data for which it is supplied. All
personal information provided will
be treated in the strictest confidence
and will only be used by the Club or
disclosed to others for a purpose
permitted by law.
Dept.
Work Address
Post code
Tele (W)
Ext
Occupation
Employee number
NHS and Cardiff University (8 digits)
E mail (work)
MEMBERSHIP CATEGORY please indicate your appropraite Pay Authority / Category
Cardiff &
Vale UHB
Velindre
NHS
Public
Health NHS
Salary/Wage
deducted
Salary/Wage
deducted
Salary/Wage
deducted
Annual
Subsciription
(RELATED)
Proposed by
Cardiff
University
Salary/Wage
deducted
ASSOCIATE
MEMBER
(OTHER)
Membership no.
CONCESSIONARY
QUARTERLY
MEMBER
Retired
Spouse
Student
Is Member’s card valid? YES / NO
Please can you confirm your preferred method of contact for future events & offers.
By letter
¤
By email
¤
¤
Neither
I confirm that ave read and understood a copy of the Terms and Conditions and that I will abide by them
Signed
For office use only
Date
Received by
Approved by
Amount Cash/card
Membership number 659410
Receipt no.
AUTHORITY FOR DEDUCTION FROM PAY
My Club fees will be paid by deduction from pay
To the Director of Finance
(please specify)
Cardiff & Vale UHB
Velindre NHS
Public Health NHS
Cardiff University
I authorise you to deduct from my pay the membership fee of the Cardiff Medical Centre Sports & Social Club at the
current rate.
Signed
Date
Employee Number (NHS & Cardiff University)
Full name
Hospital
Work address
Telephone no. (work)
Title
Dept
Post code
Ext.