Crystal Palace Fun Runners
Membership Form 1st April 2018 - 31st March 2019
ATHLETE DETAILS
FIRST NAME *
Your answer
SURNAME *
Your answer
GENDER *
DATE OF BIRTH *
(please use format dd/mm/yyyy)
Your answer
ADDRESS *
Your answer
HOME TELEPHONE NUMBER *
Your answer
MOBILE NUMBER *
Your answer
EMAIL ADDRESS *
Your answer
EMERGENCY CONTACT NAME & NUMBER *
Your answer
PERSONAL INFORMATION DISCLAIMER *
I consent to Crystal Palace Fun Runners holding personal information about me for the purpose of the administration of my membership with the club (no marketing). In doing so I consent to be being contact by the club by email, phone and text (SMS) message.
Required
Do you have an existing medical condition which might result in you requiring urgent medical attention? *
If yes please provide details below (or type 'none' for no). This information will remain strictly confidential and will only be accessible to the relevant senior club members
Your answer
Are you medically trained?
If yes please provide details ie. doctor, nurse, paramedic, first aider
Your answer
Group you usually run in or if a new member pace you normally run at *
This helps us with admin
How did you hear about us? *
This helps us with admin
MEMBERSHIP
Membership runs from 1st April 2018 - 31st March 2019.

By paying you are agreeing to abide by the clubs rules and club safety rules. These can be found on our home page.

MEMBERSHIP TYPE *
Please select the type of membership you would like from the following options:
If you are affiliating with UKA, do you agree to us sending UKA your personal details for registration?
ENGLAND ATHLETICS AFFILIATION NUMBER
(if known)
Your answer
Do you belong to another club?
Your answer
PAYMENT DETAILS
Bank transfer details: HSBC, Account Name: Crystal Palace Fun Runners, Sort Code: 40 11 58, Account Number: 20161535. Please ensure you include your name in the payment reference!
AMOUNT PAID *
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