SWC Membership 2019-2020
Please complete all the applicable boxes
Email address *
Type of Membership Required
Full Name *
Your answer
Date of Birth
MM
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DD
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YYYY
Category
Address *
Your answer
Phone number *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Number *
Your answer
Child Membership Information
Complete only if you are purchasing adult and child membership
Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Emergency Contact Name
Your answer
Emergency Contact Number
Your answer
Additional Child Membership
Only complete if you are purchasing additional child membership
Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Emergency Contact Name
Your answer
Emergency Contact Number
Your answer
About You
Please complete all of the below
How long have you been doing canicross? *
Have you competed in canicross before *
Are you interested in participating in... *
Required
What is your local club? - this will be the club your race points will go to. *
About Your Kennel
Please include details of the dogs that would be completing canicross
Dog Name *
Your answer
Dog Age *
Your answer
Dog Breed *
Your answer
Dog Name
Your answer
Dog Age
Your answer
Dog Breed
Your answer
Dog Name
Your answer
Dog Age
Your answer
Dog Breed
Your answer
Confirmation
I have read and agree to the constitution set out by South Wales Canicross (available at www. southwalescanicross.com). I agree to abide by the rules and regulations of the club ensuring that welfare of canine participants is paramount. I confirm that the details provided by myself on this form are true at the time of signing.
Signature *
Your answer
Date *
MM
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YYYY
PayPal Amount *
Your answer
PayPal Payment Reference *
Your answer
A copy of your responses will be emailed to the address you provided.
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