Courtown BMX Club Membership Application 2019
Membership Fees: €65 - 1 Member, €120 - 2 Members, €180 - 3 Members, €200 - Family membership (4 people), €20 thereafter.
** A separate Membership form must be completed for each member. **
Membership Type:
Please select:
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Personal Details:
Cycling Ireland Licence Number:
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Full Name: *
Your answer
Address: *
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Post Code: *
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Email (Parent/Guardian): *
Your answer
Home Telephone:
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Mobile Number (Parent/Guardian): *
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Date of birth: *
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Gender: *
Emergency Contact Details:
Contact Name: *
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Mobile Number: *
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Relationship to Member: *
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Medical Information:
Please detail any medical conditions the Club should be aware of and recommended treatment to be taken if symptoms appear:
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Disability Information:
The Disability Discrimination Act 1995 defines a disability as a "physical or mental impairment, which has a substantial and long term negative effect on a persons ability to carry out normal daily activities"
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Terms and Conditions:
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Required
Application Date: *
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Additional Parental Consent (for all members under the age of 16):
Name of Parent/Guardian:
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Date:
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YYYY
Parental/Guardian permission for pictures:
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