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)

……………………………………………………………………………

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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

 

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For official use only :-

 

Payment received           

Vest Issued                     

Input on…………..by…………..

Year……………………………..

      Wa Number ……………….....