Tipton Harriers Membership Form 2021/22
Mr/Mrs/Ms/Miss *
Salutation
First Name *
Surname *
Address Line 1 *
Address Line 2 *
Address Line 3
Address Line 4
Post Code *
Phone Number
Email Address *
Town and Country of Birth *
Date of Birth (DD/MM/YYYY) *
Coach
School
Event / Role *
In what way are you involved with the club? Tick all that apply
Required
Do You Consider Yourself To Have a Disability? *
If "Yes" Please Give Details and Competition Category
Emergency Contact Name
Emergency Contact Phone Number
Emergency Contact Relationship To Athlete
Name of Person For Permission For Travel and Medical Treatment
Please indicate that you agree to abide by the rules of the club *
Required
Where athlete is under 18 years of age please state consenting adults name
Membership Rates For 2020/21
The rates below are full rate with the reduced rate in brackets - the reduced rate is ONLY for members paid last year
Select Membership Rate *
Payment Options *
Name and Date of Birth of Additional Family Member
Name and Date of Birth of Additional Family Member
Name and Date of Birth of Additional Family Member
Name and Date of Birth of Additional Family Member
Any Queries?
Please contact the Membership Secretary Bryan Mills, or ask at the Tipton Harriers reception desk. email membership@tiptonharriers.co.uk
Submit
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