Please complete form and return to Mrs Mhairi
Pringle,Burnswark Farm,Ecclefechan,Lockerbie.DG11 3JJ.
ALL MEMBERSHIPS TO BE RENEWED BY 1st
APRIL 2011 OR ASAP.
First Claim Club (if appropriate)
Surname(Mr,Mrs ,Miss,Dr)
First Names
Address
..
Telephone Number
.
E-Mail Address
..
Date of Birth
..
Country of Birth
..
Preferred Events(tick) TRACK FIELD CROSS
COUNTRY FELLS ROAD
Have you been a member of another club? YES NO
(please circle)
If yes,previous club name
..
If yes ,have you resigned from previous club in
writing to club and SAL ? YES NO
Scottish Athletics Number
PLEASE NOTE: Any member taking individual
coaching on any night other than the official club training night do so at
their own risk.The club will not be liable for any injuries occurred.
Signature
Fees:-Seniors £15.00 ; Juniors £10.00 ;
Unemployed £10.00 ; Non Competing £5.00 ;Secondary First Claim £10.00 ;
Family of two or more 10% discount.
FEES PAID signed
..(membership
secretary)
DATE FEES PAID
Please note it is important that the Club is
notified of any problems or change of any medical conditions ,also any
changes of address.
PAYMENT
Payment can be made cash or cheque to ANNAN AND
DISTRICT ATHLETICS CLUB.
I understand my obligations under Scottish
Athletics Rules .I agree to abide by the constitution and rules of Annan
and District Athletics Club.
I am as far as I am aware,fit to take part in
strenuous physical activity.
Signature
..
Date
..
I consent to the above named athlete having
still and /or video images taken for publicity and /or coaching purposes.
Signature of the athlete
..
MEMBERSHIPS WILL BE DUE FOR RENEWAL ON THE FIRST
OF APRIL 2012.
EMERGENCY CONTACT AND MEDICAL REQUIREMENTS
There may be a situation in which we have to
contact you or a nominated person.The following information will be
treated in the strictest confidence -please complete as fully as you can
thankyou.
ATHLETES NAME
ADDRESS
..
TELEPHONE NUMBER
.
ATHLETES DATE OF BIRTH
EMERGENCY CONTACT NAME
.
TELEPHONE NUMBER
.
DOCTOR
.
TELEPHONE NUMBER
..
Please give details below of any medical
condition which you may feel is relevant and any medication required ie
inhalers
Do you suffer from any allergies? MEDICATION
..
NUTS
.
OTHER (PLEASE SPECIFY)
..
CONSENT FOR TAKING AND USING IMAGES OF MEMBERS
OF ADAC.
The purpose of this form is to ensure the club
has the optimum flexibility to allow filming which you would support.Your
permission is sought in advance to take ,display,transfer and on
occasions,publish photographs and video recordings involving you. It is
intended that your consent will cover the whole of the time you are a
member ofADAC. There will be annual checks on consents given but you are
able to make changes at any time,in writing ,to the club. Please answer
each question Yes or No . However ,if you wish to enter either Yes to all
items or No to all items,please tick below.
YES TO ALL QUESTIONS NO TO ALL QUESTIONS
Annan & District Athletic Club