Chequers Netball Club Membership Form
Date of Birth
School / College
Email Address 1
Email Address 2
Under 18's only
If you do not wish your contact details to be shared with other club members please tick here
This is for Senior Squad members only
Please do not share
White - British
White - Irish
Any other White background (please specify below)
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Any other mixed background (please specify below)
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Any other Asian background (please specify below)
Black or Black British - Caribbean
Black or Black British - African
Any other Black background (please specify below)
Prefer not to say
Do you consider you to have a disability
If Yes to above, please state nature of disability
Do you have any known allergies or medical information that we should know about?
If Yes to above, please state nature of condition
Please provide details of medication that must be administered
Do you have any past or current injuries that we should be aware of?
If Yes to above, please provide all relevant details
EMERGENCY CONTACT INFORMATION
Please give name, relationship and a contact telephone number
What section of the club are you from?
B2N Wednesday Nights
B2N Thursday Nights
If you are in the senior section, what team have you been selected for for the 2014/15 season?
Are you a new member of the club?
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