Killorglin Rowing Club Membership Form 2017
(Please e-mail killorglinrowingclub@gmail.com once the form is submitted)
Full Name
Your answer
Home Address
Your answer
Date of Brith
MM
/
DD
/
YYYY
Contact Number
Your answer
Email Address
Your answer
Able to Swim?
Medical Information and Consent (mandatory)
(To be completed by Parent or Guardian if applicant under the age of 18 years). In case of emergency, and as part of the Club's responsibility to it's membership, ALL prospective Club members are required to complete this medical information form as accurately as possible. All medical information will be held securely with access restricted to authorised Club Officers only.
Your answer
Next of Kin
Your answer
Relationship
(Mother, Father etc.)
Your answer
Contact number in case of Emergency
Your answer
Doctor's Name
Your answer
Surgery
(Address, contact number)
Your answer
Are you allergic to any drugs ?
If allergic to any drugs please list them below
Your answer
Are you on medication ?
If on medication, please list it below
Your answer
Long term illness or injuries ?
If you have long term illness or injury please provide details below
Your answer
Declaration and Consent
I consider myself / my son / my daughter to be physically fit and capable of full participation in the activities of Killorglin Rowing Club and agree to notify the Club of any changes to the medical information provided above. Furthermore, in the event of that I / my son / my daughter (delete as appropriate) am/are injured, I give my permission for the team managers and/or coaches of Killorglin Rowing Club and/or any other Rowing Club to obtain emergency medical treatment on my behalf.
Signed
(Name, Date and Relationship to the applicant)
Your answer
Consent re Transportation and Photography
(To be completed by Parent or Guardian if applicant under the age of 18 years). Transportation: I consent to my son / my daughter (delete as appropriate) travelling to venues for regattas an training by transport provided by the Club which may include travelling in other members private cars. Photography: In some environments, particularly during competition, it is impossible to control photography by external parties. I am aware that at times photographs and or video footage will be taken during regattas and training sessions by approved agents and/or authorised officers of rowing clubs. These images will only be used for publicity and/or training purposes in accordance with Killorglin Rowing Club's Code of Ethics, and I give my consent for my son / daughter (delete as appropriate) to feature in such photographs and/or video footage. I also grant approved agents the right to use the images resulting from the photograph/video shoots. This includes any reproduction or adaptation of the images for all general purposes Club's website and Facebook pages.
Signed
(Name, Date, Relationship to the applicant)
Your answer
Application for membership and Waiver of Liability
I wish to join Killorglin Rowing Club and agree to pay the required membership. In joining I agree to abide by the Club's Rules and Guidelines in the Code of Ethics and Good Practise for Sport for Young People. I understand that participation in the sport of rowing can result in personal injury. I fully understand the risks involved and hereby agree to participate in training and competition voluntarily and entirely at my own risk. The rules and regulations of Killorglin Rowing Club are designed for the safety and protection of all members and I hereby agree to abide by them. In consideration of my acceptance and participation in Killorglin Rowing Club's training and competion programmes, I agree that Killorglin Rowing Club, its Officers, Coaches, Volunteers, Members, and Management Committees will not be liable for any losses or injuries sustained by me, or in any way resulting from my participation in the activities of the Club.
Signed
(Name, Date, Relationship to the Applicant/ Applicant)
Your answer
Membership Fees (Sliders Sept - July) (Coastal Apr- Sept)
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