Benson Striders membership form
Please complete our membership application form below. Fields marked with an * are mandatory.
Email address *
First name *
Your answer
Middle name
Your answer
Last name *
Your answer
Known as
Your answer
Date of Birth
MM
/
DD
/
YYYY
Sex *
Mobile number
(or landline if you prefer)
Your answer
Address line 1
Your answer
Address line 2
Your answer
Town
Your answer
County
Your answer
Post code
Your answer
1st Emergency Contact Name
We like to keep all our members safe, just in case of an emergency. Therefore we ask you to provide two emergency contact details. Please note that your Emergency contacts will be printed on your ICE tag
Your answer
1st Emergency Contact Number
(eg. as per ICE tag)
Your answer
1st Emergency Contact Address
Your answer
2nd Emergency Contact Name
(eg. as per ICE tag)
Your answer
2nd Emergency Contact Number
(eg. as per ICE tag)
Your answer
Have you done any running before?
Do you have any other health considerations/previous injuries we should know about, or any condition requiring medication? (this info will go on your ICE tag)
Your answer
For Women: Are you currently pregnant/breastfeeding or had a baby in the last 6 months?
Couch to 5k? *
(are you / have you taken part in couch to 5k with Benson Striders)
Permission to use photos? *
from time to time Benson Striders wish to use photos to share on facebook, the website, newsletters, promotional material and other media. Please select NO, here if you DON'T wish photos of you to be shared.
Code of conduct *
I hereby confirm that I participate in Benson Striders running groups completely at my own risk and state that I do not hold Benson Striders or any of its representatives responsible for any injury, loss or accident incurred. I accept that I will be running on the highways, pavements and roads and agree to take full responsibility for following the Highway Code when running. I agree to provide my own reflective vest, armband or similar high visibility clothing, and/or head torch to make me visible, and wear it when running at night or when advised. I agree that I know not of any medical or physical reason why I should not participate in Benson Striders and if under supervision from my doctor that I have permission from my doctor to allow me to participate. If I am unsure of my suitability to participate I will gain permission from my doctor. If I develop any new relevant medical or physical condition, I will inform Benson Striders. I understand that my personal details will be held on computer by the club solely for the purposes of club administration, management and communication and shared with an appropriate third party for the printing of ICE Tags. If I choose to affiliate to England Athletics my details will be passed onto England Athletics. Competition providers may be passed a copy of the data necessary for their event. I will abide by the Benson Striders Code of Conduct.
Required
Membership fee *
Our membership fee is due on or before 1st April. You can have 1 free taster sessions before you decide to join. We'll discuss what this includes when we see you. Payment should be made to: Benson Striders Running Club Account: 19660960 Sort Code: 30-99-63 Reference: subs/year/your name e.g. subs2016PeterJones. Sorry NO membership NO running with the groups (unless you are on your trial session). All members are provided with an ICE (in case of emergency) Tag which stores emergency information. The bar code is also used to record your attendance and this information will only be used by the club.
A copy of your responses will be emailed to the address you provided.
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