Tipton Harriers Membership Form 2020/21
Mr/Mrs/Ms/Miss *
Salutation
First Name *
Your answer
Surname *
Your answer
Address Line 1 *
Your answer
Address Line 2 *
Your answer
Address Line 3
Your answer
Address Line 4
Your answer
Post Code *
Your answer
Phone Number
Your answer
Email Address *
Your answer
Town and Country of Birth *
Your answer
Date of Birth (DD/MM/YYYY) *
Your answer
Coach
Your answer
School
Your answer
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
Your answer
Emergency Contact Name
Your answer
Emergency Contact Phone Number
Your answer
Emergency Contact Relationship To Athlete
Your answer
Name of Person For Permission For Travel and Medical Treatment
Your answer
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
Your answer
Membership Rates For 2020/21
Select Membership Rate *
Payment Options *
Name and Date of Birth of Additional Family Member
Your answer
Name and Date of Birth of Additional Family Member
Your answer
Name and Date of Birth of Additional Family Member
Your answer
Name and Date of Birth of Additional Family Member
Your answer
Any Queries?
Please contact the Membership Secretary Bryan Mills, or ask at the Tipton Harriers reception desk. email membership@tiptonharriers.co.uk
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