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 Secretary (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
WA number ... .
.
Please give details of any medical conditions / medication that we should
be aware of (asthma, heart conditions, epilepsy etc)
Annual Subscription Fees
New member : Total fee is £40
Renewal Fee : £40
Second Claim / Social Member : £25
Cheques payable to "Abergele Harriers".
Club vests can be purchased at cost price from Mark Mayers
___________________________________________________________
For official use only :-
Payment received ○
Vest Issued ○
Input on ..by ..
Year ..
Wa Number .....