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BICESTER ATHLETIC CLUB

MEMBERSHIP APPLICATION

SURNAME: ...............................................    FIRST NAME: ............................................

ADDRESS ..........................................................................................................................

POST CODE ..............................................    PHONE NO ................................................

DOB ...........................................................   AGE ........................…….MALE/FEMALE

SCHOOL: (if applicable) ......................................................................................................

I wish to become a member of Bicester Athletic Club and declare that:

1.         I will abide by the rules of the Club, a copy of which can be inspected upon application to the Secretary

2.         I will abide by the rules of the Athletic Association, to which the Club is affiliated

3.         I wish to apply for:

             JUNIOR (£10) o  SENIOR (£15) o  FAMILY (£25) o  SOCIAL (£10)  o

            Please tick appropriate box.  If applying for family membership a separate form should be completed for each member. Cheques should be made payable to Bicester Athletic Club

4.         I am / am not a member of another AA Affiliated Club

            If yes, please give details ..........................................................................1^ST/2^ND CLAIM

5.         I am interested in:

            ROAD RUNNING  o  CROSS COUNTRY  o  TRACK & FIELD  o SOCIAL  o

            COACHING  o   HELPING/ASSISTING  o                 Please tick appropriate box/boxes

6.         Please give details of any medical conditions ( asthma, allergies etc) :

                        .................................................................................................……..................................................

                        ..................................................................................................................................................…….

SIGNED .............................................................................. (Parent/Guardian if under 18)

DATE ………………………………………..

Under the terms of the Data Protection Act we have to inform you that your membership details will be stored on a computer.  We can assure you that the above details will not be used other than for Club administration.  If you object please tell the Membership Secretary and arrangements will be made to store your details on paper only.

Please return completed application and payment to:  Derek Colden, 3 Chestnut End, Bicester                                                                                                                                                     Telephone 01869 240846