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MEMBERSHIP FORM – 2015
PLEASE COMPLETE ALL RELEVANT SECTIONS OF THIS APPLICATION
We are pleased to welcome you to Oldham and Royton Harriers & A.C. To ensure that we
have the correct contact details for you please insert the information requested below and
return this form to Paula Booth (Monday’s) or Martin Hilditch (Thursday’s) in Reception.
New for 2015! - A Start Fitness card will be issued to all members. Register online to
receive a year round offer of 30% off More Mile products - www.moremile.co.uk
Personal Details
(BLOCK CAPITALS, please)
Surname
First Name
Date of Birth
Address
Postcode
Landline:
Mobile:
Email Address
Emergency Contact Number:
Name:
Relationship:
IMPORTANT: Please state any medical condition
and/or medication which should be drawn to the
attention of the coaches.
If you are a member of another club and are
joining us 2nd claim, please state the 1st claim
club.
There are a number of volunteering roles that we need to fulfil to improve the experience of people
associated with the club. If you would like more information please tick here:
[ ]
I, the undersigned, wish to apply for/ renew membership of Oldham and Royton Harriers and AC. If
granted membership of the club, I promise to abide by the Club’s Constitution & Rules at all times.
In being a member of Oldham and Royton Harriers and AC I understand that there is an expectation that
I/my child will represent the club in competition. There are opportunities in the following competition
formats; Track and Field/ Road Running/ Sportshall/ Cross Country.
Signature
(of Parent/Guardian if applicant under 16)
Oldham and Royton Harriers and AC Membership: 1 Jan 2015 to 31 December 2015
*2015 Membership of England Athletics has increased to £12
Membership Categories:
Rockets U11 - £32 includes Membership of England Athletics
Juniors Under 20 - £40 includes Membership of England Athletics
Seniors - £48 includes Membership of England Athletics
Family - £55 plus the cost of England Athletics Membership for each athlete
University Students - £20 includes Membership of England Athletics
Trainers for other sports - £15 (EA affiliation fee not required)
£…………
£…………
£…………
£…………
£…………
£…………
Payment in full by 31 January 2015
Total
£…………
BACs
Paid by:
Cheque
Cash
The completed membership form and payment only should be given to the Club
representative in Reception.
(Cheques payable to Oldham and Royton Harriers and Athletic Club)
BACs: Sort code 40-35-26 Account 30633607.
With BACS payment use the Athlete’s name as reference.
If you encounter problems when paying by BACs please contact the Club Treasurer Paula Booth
[email protected]
DISABILITY
The Disability Discrimination Act 1995 defines a disabled person as anyone with “a physical or
mental impairment, which has a substantial and long term adverse effect on his or her ability
to carry out normal day-to-day activities”.
Do you consider yourself to have a disability?
Yes
[
]
No
[
]
If yes, what is the nature of your disability? Please tick / write below.
Physical disability
[
]
Learning disability
[
] Multiple disability
[
]
Visual impairment [
]
Hearing impairment
[
] Other – please specify below [
]
Prefer not to say
]
[
ETHNICITY
In order to help the club monitor its membership can you please tick one of the following
boxes to identify your ethnic group / origin.
Choose one section from A to F and then tick the appropriate box.
A WHITE
B MIXED
British
Irish
Other - Please
specify
D BLACK OR BLACK BRITISH
C ASIAN OR ASIAN BRITISH
White and Black
Caribbean
White and Black
African
White and Asian
Indian
Other – Please
specify
Other – Please
specify
Chinese
African
Other – Please specify
F PREFER NOT TO SAY
[
]
Bangladeshi
E CHINESE OR OTHER ETHNIC GROUP
Caribbean
Other – please specify
Pakistani
Photographic/ Video Policy:
On occasions, photographs may be taken of athletes competing, and these may be published
in appropriate locations. The Club follows the England Athletics Policy which is available on
our website. Child Protection Regulations require parental/guardian permission for use of
images, please tick the appropriate box below:
I give consent for the club to use images in line with England Athletics Policy
[ ]
I do not give consent for the club to use images
[ ]
The details from this form are held on paper and Oldham and Royton Harriers and AC
database for the year. Periodically, the club may pass membership details to England
Athletics, as necessary. No details are passed to any other outside organisation.
Additional family members
Personal Details of Applicant(s)
(BLOCK CAPITALS, please)
First Name
Surname
Address
Date of Birth
Post Code
Email Address
Tel Number
School Attended (Juniors Only)
IMPORTANT: Please state any medical
condition and/or medication which should be
drawn to the attention of the coaches.
Membership of any previous Athletic Club
and date of resignation.
Signature
(of Parent/Guardian if applicant under 16)
First Name
Surname
Date of Birth
School Attended (Juniors Only)
IMPORTANT: Please state any medical
condition and/or medication which should be
drawn to the attention of the coaches.
Membership of any previous Athletic Club
and date of resignation.
Signature
(of Parent/Guardian if applicant under 16)
First Name
Surname
School Attended (Juniors Only)
IMPORTANT: Please state any medical
condition and/or medication which should be
drawn to the attention of the coaches.
Membership of any previous Athletic Club
and date of resignation.
Signature
(of Parent/Guardian if applicant under 16)
Date of Birth