ABERGELE         HARRIERS

Membership Application Form

I acknowledge that my personal details, as stated below, will be held on file by Club Officers.  I agree to this information (name, address, phone numbers, email address) being made available to other Members via written requests from members to the Membership Secretaries (please indicate) YES / NO

Title :                     Mr              Mrs             Miss            Ms

Surname :    ……………………….   First Name : ……………………….

Address :     ……………………….

                   ……………………….

                   ……………………….   D.O.B :…………………………….

                   ……………………….

                   ……………………….   Place of birth :……………………...

Postcode :   ……………………….

Home Phone :        ……………………….

Mobile :                 ……………………….

Email address :      ……………………………………..

Emergency contact name & number : ……………………………………..

………………………………………………………………………………………………………………………………………………………………

Welsh Speaking?   Yes             No

Nationality :  ……………………….

Membership required :

○ New Membership

    Please indicate vest size required :- Ladies – 10 12 14 16  18

                                                          Men – S  M  L  XL  XXL

○ Renewal Membership

○ Second Claim / Social Member

If second claim member, please give details of first claim club and        AAW number………………………………………………………….

………………………………………………………………………….

Please give detals  of any medical conditions / medication that we should be aware of (asthma, heart conditions, epilepsy etc)

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Annual Subscription Fees

New member : Total fee is £45 – 2 separate cheques required – 1 made payable to Abergele Harriers for £30 (includes insurance and running vest) and the other made payable to Welsh Athletics for £15.

Renewal Fee : £35 – again, 2 separate cheques required £20 to Abergele Harriers and £15 to Welsh Athletics

Second Claim / Social Member : £20 payable to Abergele Harriers.

Payments can be sent to either of the membership secretaries :-

Cheryl Richards         or      Lucy Jones

Tir Eithin                    Cilmeri

Maes Y Bryn                       Sarn Road

Berthengam                          Trelogan

Flintshire                              Flintshire

CH8 9BA                            CH8 9BZ

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For official use only :-

Payment received            ○

Vest Issued                      ○

Input on…………..by…………..

Year……………………………..

      AAW Number ……………….....