MEMBERSHIP FORM

Application for membership of the club

To the Club Committee

I apply to be elected to First/Second Claim/Higher Comp/Student  Training Membership of Liverpool Harriers & Athletics Club

I hereby declare that I am an amateur as defined by  British Athletics UK.

This document is to be completed by the applicant and returned to the club secretary  with the annual subscription as shown below:

	Senior Member	£30
	Member aged 15 to 19, Students & Unemployed -i.e. (U/17M&W to junior M&W)	£20
	Members aged under 15 and over 11 years (i.e. U/15B&G and U/13B&G, School Yrs 6, 7, 8 and 9)	£15
	Members under 11 years (i.e. School Yr 5 and under)	£10
	Minimum age for membership is 9 and over
	Age as on 31st August/1st September 2007

The subscription includes a registration fee to be paid to England Athletics

Annual subscription become due on the 1st January each year

Name  ........................................................................................    D.O.B..............................Place of Birth.................................

Address  ..................................................................................................................Post code............................

Telephone Number  .......................................................Mobile Number...................................................

Signature of Applicant  ............................................................................  Date  ..................................

If under 18 years of age,  signature of parent or guardian  ......................................................................

Additional Contact Number in case of emergency..................................................................................

If you are, or have been during the last 2 years, a member of another athletics club, please give details.

Name of Club  ......................................................................................................................................

If you have resigned, please state   ..........................................................................

NOTE:  Data Protection Act.  Details given on this document will be held on computer discs and will be used in the administration of the club, and will be made available to the North of England AA for the purpose of  registration with the North of England AA. I agree to allow the North of England AA to use the information supplied by the club to be used for fund raising for the North of England AA .

YES  / NO...........................................SIGNED

If at school, please give name of school  ..............................................................................................

Events in which you are interested  .....................................................................................................

If you have a medical condition or are taking medication of which your coach or team manager should be aware, please give details. This information will only be given to coaches or team managers on a 'need to know' basis

Proposer  .......................................................................  Seconder  ..................................................

Date of Election  .............................................  Signed - Club Secretary ............................................. 

TO PRINT THIS FORM, Highlight the entire form, GO TO File>Print, then check the PRINT SELECTION box and then press print.