MEMBERSHIP SECRETARY Raymond Hall
29 Hainsworth Moor Grove, Queensbury, Bradford, BD13 2ND
Tel 01274 814632
email [email protected]
JUNIOR (under 18 years)
Membership Form 2017
Please enter any MEDICAL CONDITIONS and
complete the SURVEY on the back of this form
First Name
Date of Birth ____/_____/______
_________________ Surname_________________
Gender MALE / FEMALE
Address
___________________________________________________________________
Town
______________________________
Post Code ___________________
PLEASE PRINT CLEARLY
e-mail
please
Home
Phone
Mobile
Phone
IMPORTANT:- I hereby apply for MEMBERSHIP of the HALIFAX HARRIERS AC for the above
person. I promise that my son/daughter will compete for the club in either Track & Field or Cross
Country Competitions, when they reach the required standard.
(Remember to complete the survey on the rear of this form)
IF YOU ARE A MEMBER OF ANOTHER
ATHLETICS CLUB ENTER CLUB NAME IN THE BOX
OTHER
CLUB
Signed ____________________________________
Date _____/______/_______
(Parent or guardian)
UNDER 18 YEARS CONSENT
I understand that by completing and submitting
this form I am giving my consent for my child to
participate in the relevant activity. Furthermore, I
understand that should medical treatment be
necessary, every reasonable effort will be made to
obtain the consent of the emergency contacts named
below. However, in an emergency, I authorise the
coaches to consent on my behalf to any medical
treatment, which a qualified doctor feels is necessary.
There may occasionally be photographs taken
by official photographers. They will be complying with
strict child protection guidelines. I give my consent for
my child’s image to be used in newspapers or future
promotions.
UNDER 18 YEARS ONLY
Parent / Guardian Details & Consent
Name
_________________________________
Relationship to athlete
Parent / Guardian
Due to the high demand for places in our
Junior Section, we are not accepting
applications from new members who only
wish to train for general fitness, or to
improve their fitness for another sport
(football, rugby, netball etc).
Category
ALL MEMBERS
(Minimum age 8 years)
Family discounts
(All must live at
same address)
2 members at
£40. Total
discount £10
Subscription fee
For October 1st 2016
to Dec 31st 2017
£40
3 members at
£40. Total
discount £15
4 members at
£40. Total
discount £20
PLEASE MAKE CHEQUES PAYABLE TO
‘HALIFAX HARRIERS’
Data Protection Act 1984: - Only your name, address, date of birth,
telephone number and email will be held on the club computers.
Home Phone _____________________________
Mobile Phone _____________________________
Signature
_____________________________
Date
________ / ________ / __________
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Harriers Coaches Deb Greenwood or Jamie Bush to sign before
application for membership will be accepted. (After 4 week trial)
DATE TRIAL STARTED ______/______/_____
Please enter any medical conditions in this box.
√
Please tick ALL STATEMENTS that apply
I intend to compete for Halifax Harriers in Track and Field Competitions
I intend to compete for Halifax Harriers in Cross Country Races
I intend to compete for Halifax Harriers in Road Races
I intend to compete for Halifax Harriers in Trail Races
I intend to compete for Halifax Harriers in Fell Races
You may train with the club for 4 weeks before joining. This period is to allow you
time to decide if you would like to be a part of this club.
There is a charge of £2 per night to pay until you join. The £2 charge is payable for
training both on the track and with the road running groups.
Once the membership fee on the front of this form has been paid you no longer pay
the £2.
SPECIAL OFFER ON CLUB VESTS AND T-SHIRTS
The standard price of a Club Vest is £18 and a Club T-Shirt £20. If you wish to
purchase either, of these items when you apply for membership of Halifax Harriers
we are offering them at £10 each. (You may only purchase ONE item)
If you decide to purchase either item at a later time the full price will apply.
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