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Mossley Hill Athletic & Social Club
Athletics and Running Section
Application for Membership
April 2015 – March 2016
I wish to become a first claim member of Mossley Hill Athletic Club, registered with England Athletics. I shall
abide by the rules and constitution of the Club in accordance with amateur athletic rules.
I undertake to pay the subscription as fixed by the Committee and acknowledge that my membership liability is
considered continuous until written notice is given to the membership secretary.
I agree that at no time will my behaviour on club premises or whilst representing the club impair the good
name of the club.
* fields must be completed
Title*
Mr
Mrs
First Name*
Miss
Ms
Doctor
Other
circle appropriate
Surname*
Address*
Town/City*
County*
Post Code*
Telephone*
Date of Birth*
e-mail address
Where provided, email addresses may be used to update members on training activities, section social events and other information.
If you do not wish to be contacted in this way, please leave the email address blank.
News and updates can also be obtained on the section's website at www.mossleyhillrunning.org.uk
I enclose my subscription fee of £45, which includes full social membership of Mossley Hill Athletic
& Social Club and registration with England Athletics.
Signature*
Date*
Please hand this form to any member of the Running Section Committee along with your payment. The fee can be paid as cash or
cheque. Cheques should be made payable to “Mossley Hill Athletic Club”. Please write running section on the back of cheques.
Please allow 28 days for acceptance by the committee.
Medical Information: If you have a medical condition or are taking medication of which you feel we should
be aware, please give details. This information will be held in confidence and only shared with coaches or
team managers as necessary.
Data Protection: As a not-for-profit club, the Mossley Hill Athletic Club Running Section is exempt from the requirement to
notify under the Data Protection Act 1998. The personal and contact data you provide is held solely for the purpose of establishing
and maintaining membership records, including your registration with England Athletics, and administering and publicising activities
to members.
For Committee use
Proposed by
Date
England Athletics URN
Section Attachments
Invoice number
Payment Type
Cash
Cheque