Mote Runners Membership Form

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Title *

Forename *

Surname *

Date of Birth *

YYYY

Email *

Telephone *

Address *

Postcode *

Gender *

Female

Male

Nationality *

Disability

Emergency contact name *

Emergency Contact telephone number *

Select if you wish to be added to either of the Mote Runners WhatsApp groups below.

Mote Runners general chat group

Mote Runners 5k challenge group

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 and provide your England Athletics registration number (URN)

Club membership type/cost: *

Club membership without England Athletics registration £20.

Club membership with England Athletics registration £36.

Club Membership 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.

Registering with England Athletics: When you become a member of or renew your membership with Mote Runners and are 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: (select option 1 for club membership and additionally 2 if also registering with England Athletics. *

1. 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.

2. 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.

Required

Signature *

Date *

YYYY

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