Contact / Info
Contacts. p.watson2@sky.com or goggins34@gmail.com
Pudsey and Bramley athletics club
Membership form
We are very pleased to welcome you to PUDSEY & BRAMLEY AC
To ensure that we have the correct contact details for you, please insert the information requested below and return this form to the club secretary, Tracey Dutton.. If you are under 16 please also ask your parents or guardian to sign the form before it is returned.
We will also use this information to ensure that you are kept informed about club events.
Personal details
Name: ...........................................................................................................................
Address: ......................................................................................................................
..................................................... Postcode: ............................................................
Home telephone number: .......................................................................................
Mobile: ............................................................
E-mail address: ……………………………………………………………………..
Date of birth: ................................ Gender:.......................... Male ¨ Female ¨
Please indicate here if you are not happy for your details to be shared with other members (our aim is to send out an updated list every year to our members) ¨
In order to help the club monitor its membership can you please tick one of the following boxes to identify your ethnic group:
White............................................................. ¨
Mixed............................................................ ¨
Asian or Asian British................................ ¨
Black or Black British................................. ¨
Chinese or other ethnic group................. ¨
Do you consider yourself to have a disability?............................... Yes ¨ No ¨
If yes, what is the nature of your disability? ..........................................................
Sporting information
Have you been a member of an athletics club before? ............... Yes ¨ No ¨
If yes, which clubs: (please indicate below)
………………………………………………………………………………………….
medical information
Please detail below any important medical information that our coaches/junior coordinator should be aware of (e.g epilepsy, asthma, diabetes, etc.)
........................................................................................................................................
........................................................................................................................................
Emergency contact details -
to be completed by parent/guardian
Please insert the information below to indicate the person(s) who should be contacted in case of an incident/accident:
Contact name (e.g parent/guardian): ......................................................................
Emergency contact number:......................................................................................
By returning this completed form, I agree to my son/daughter/child in my care taking part in the activities of the club.
I understand that I will be kept informed of these activities - for example timing and transport details.
I understand that in the event of any injury or illness all reasonable steps will be taken to contact me, and to deal with that injury/illness appropriately.
Name of parent/guardian:..........................................................................................
........................................................................................................................................
Signature of parent/guardian: ..................................................................................
Date: ..............................................................................................................................