NEW Members Application Form

The form may be filled in on a computer (preferred) or printed and filled out by hand in BLOCK capitals.

Name:	Sex:
Address:
Postcode:
Home Phone:	Mobile Phone:
Date of Birth:	Email:
Occupation:
Previous Club: (if applicable)	England Athletic No: (if applicable)
Are you Welsh speaking?	☐
Emergency Contact
Name:	Relation:
Phone:
Type of membership (Please tick)
Senior	Includes Club Vest + XC fees	£45
Junior (Under 17)	Includes Club Vest	£20
Junior (Under 17) Family Discount*	Includes Club Vest	£16
Associate (Non-competitive member. Not affiliated with governing body)	Includes invites to all club events	£10
* Only applies to children whose parent has been a senior member for at least 1 year
Vest Size
Men’s	Small	Medium	Large	X Large	XX Large
Ladies	X Small	Small	Medium	Large	X Large

Medical Details
Please declare all long term or permanent medication in use
I am on NO medication that is a banned substance
I am on the medications below as prescribed by my doctor
Medication:
Doctor’s Name:	Phone:
Address:

Disability

The Disability Discrimination Act 1995 defines a disabled person as anyone with “a physical or mental impairment, which has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities”.

Do you consider yourself to have a disability?	No	Yes
If yes, what is the nature of your disability?	Visual impairment
Hearing impairment
Physical disability
Learning disability
Multiple disability
Other (please specify)

Ethnicity

In order to help the club monitor its membership, please will you select one of the following boxes to identify your ethnic group/origin.

A	White
British
Irish
Other White background (please specify):	:
B	Mixed
White & Black Caribbean
White & Asian
White & Black African
Other Mixed background (please specify):	:
C	Asian or Asian British
Indian
Pakistani
Bangladeshi
Other Asian background (please specify):	:
D	Black or Black British
Caribbean
African
Other Black background (please specify):	:
E	Chinese
Any other background (please specify):	:

Please accept the following before signing

I wish to join Wellingborough & District Athletic Club membership and agree to accept the Club rules and constitution (available at wdac.org.uk) and agree to abide by the rules of UK Athletics. I am NOT a member of any other athletic club.

I Accept	Name/Signature:	Date:
If the applicant is under 17 years old a parent or guardian MUST also sign below
I Accept	Name/Signature:	Date:

Please note:- your home details may be given to other Wellingborough & District Athletic Club committee members. If you have any problems with this, PLEASE do not fill them out.

In accordance with the provision of the Data Protection Act 1998 any personal data which is supplied to the Wellingborough and District Athletic Club will be held in a secure database and used solely for the purpose of Wellingborough and District Athletic Club. The information provided will not be passed to any third party.

You may email forms to membership@wdac.org.uk

Print them out and hand them in at the club

Post them to Alan Mills, W&DAC Membership Secretary,

12 The Dale, Wellingborough NN8 3QL

Payment can be made online at www.wdac.org.uk/paynow or can be a written cheque made payable to Wellingborough & District A. C.