Mote Runners Membership Form

Title *

Forename *

Surname *

Date of Birth *

YYYY

Address *

Postcode *

Email *

Telephone *

Gender *

Female

Male

Nationality *

Disability

Emergency contact name *

Emergency Contact telephone number *

Do you intend Mote Runners to be your first Claim Club? *

Yes

Do you have a current or previous registration with another club? *

Yes

If yes; please provide the name of your first claim / previous club

Please provide your England Athletics registration number (URN)

Club membership type/cost: *

Club membership without England Athletics registration £20.

Club membership with England Athletics registration £35.

Required

Club declaration

Not registering with England Athletics: You will not be registered with England Athletics, and your details will be held by Mote Runners for Club Administration and communication purposes only.

I declare that: *

That I am medically fit to run at the date of this application and that I will notify the club committee of any changes in my medical condition.

I understand that while all reasonable precautions will be taken to ensure my safety, I remain responsible to assess my personal risks and the risks I may pose for others. I hereby agree that Mote Runners shall not be liable for any injury, accident, loss or damage to myself due to my participation in any events organised by Mote Runners.

Required

Club declaration registering with England Athletic

Registering with England Athletics: When you become a member of or renew your membership with Mote Runners you will automatically be registered as a member of England Athletics. We will provide England Athletics with your personal data which they will use to enable access to an online portal for you (called myAthletics). England Athletics will contact you to invite you to sign into and update your myAthletics portal (which, amongst other things, allows you to set and amend your privacy settings). If you have any questions about the continuing privacy of your personal data when it is shared with England Athletics, please contact dataprotection@englandathletics.org.

I declare that:

That I am an amateur as defined by the UK Athletics Rules and will abide by their rules.

I understand the England Athletics GDPR statement above.

Signature *

Date *

YYYY

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