Family Subscription Form – Kings Lynn Cycling Club

Part 1a - About You - First Adult

Adult 1 - Your Name *

First

Last

Adult 1 - Your Gender *

Adult 1 - Your Date of Birth *//

Adult 1 - Your Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Adult 1 - Your Telephone Number *

Adult 1 - Your Mobile Phone Number *

Adult 1 - Your Email *

Confirm Email

Adult 1 - Are you already a member of any other cycle clubs? *

Please select "yes" if you are already a member of another cycling club. If not please select "No"

Adult 1 - Please list any existing cycle club memberships here *

Adult 1 - Emergency/Next of Kin Name *

First

Last

In case of an emergency, please enter the name of your next of kin.

Adult 1 - Emergncy/ Next of kin Telephone Number *

Please enter the corresponding telephone number of your next of kin.

Part 1b - About You - Second Adult

Adult 2 - Your Name: *

First

Last

Adult 2 - Your Gender *

Adult 2 - Your Date of Birth *//

Adult 2 - Do you live at the same address? *

Adult 2 - Your Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Adult 2 - Would you like to add another telephone number? *

Adult 2 - Your Telephone Number: *

Adult 2 - Your Mobile Phone Number *

Adult 2 - Would you like to add another email address? *

Adult 2 - Your Email *

Confirm Email

Adult 2 - Are you already a member of any other cycle clubs? *

Please select "yes" if you are already a member of another cycling club. If not please select "No"

Adult 2 - Please list any existing cycle club memberships here: *

Adult 2 - Emergency/Next of Kin Name *

First

Last

In case of an emergency, please enter the name of your next of kin.

Adult 2 - Emergncy/ Next of kin Telephone Number *

Please enter the corresponding telephone number of your next of kin.

Part 2a - About You - First Junior

Junior 1 - Your Name: *

First

Last

Junior 1 - Your Gender *

Junior 1 - Date of Birth: *//

Junior 1 - Do you live at the same address? *

Junior 1 - Your Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Junior 1 - Do you have any medical conditions, allergies or injuries that the club should be aware of? *

Junior 1 - Please detail any medical conditions, allergies or injuries that the club should be aware of here: *

Part 2b - About You - Second Junior

Junior 2 - Your Name: *

First

Last

Junior 2 - Your Gender *

Junior 2 - Date of Birth: *//

Junior 2 - Do you live at the same address? *

Junior 2 - Your Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Junior 2 - Do you have any medical conditions, allergies or injuries that the club should be aware of? *

Junior 2 - Please detail any medical conditions, allergies or injuries that the club should be aware of here: *

Part 3 - Subscription Fees

Price of Family membership:

Price: £ 35.00

Are you paying by Cheque or Bank Transfer (BACS)? *

Cheque
BACS

Would you like a copy of the "Cycling Time Trials" (CTT) handbook? - £15.00 *

YES I would like a copy of the CTT handbook
NO I would not like a copy

If you would like a copy of the Cycling Time Trials (CTT) handbook. Please select "Yes". If not select "No". Prices include P&P.

Would you like a copy of the "Cycling Time Trials" (CTT) East District handbook? - £3.00 *

YES I would like a copy of the East District CTT
NO I would NOT like a copy

Voluntary financial contribution *

Yes I would
No thanks

Would you like to make a voluntary financial contribution to the club? If so click "Yes, otherwise click "No".

How much would you like to contribute? *

Please state the amount you would like to contribute here

Annual subscription fee - Total:

£ 0.00

This is the total amount required for your chosen membership subscription.

Part 4 - Consent

Please read and observe the following options carefully.

I hereby consent that the information provided on this form can be held by Kings Lynn Cycle Club for the duration of my membership of the club. *

I consent
I do not consent

I consent to be contacted by electronic mail (e-mail). *

I consent
I do not concent

I understand that should I join the KLCC Facebook group that I may be receive communications through this social media. *

I consent
I do not consent

(Adult) I consent that appropriate photographs and videos recorded during club activities may be used in club publicity. *

I consent
I do not consent

(Junior) Images of members under the age of 18 will never be identified or named without parental consent and will only be used in accordance with the Clubs child protection/photography policies and Best Practice guidelines. *

I consent
I do not consent

I consent in the event of an incident during club activities the emergency contact provided may be contacted. *

I consent
I do not consent

(Adult) In the event that the above named member(s) is injured whilst in the care of the club: *

I give consent for medical treatment to be administered
I do NOT give consent for medical treatment to be administered

(Junior) In the event that the above named member(s) is injured whilst in the care of the club: *

I give consent for medical treatment to be administered
I do NOT give consent for medical treatment to be administered

I agree to the terms of service.

I will abide by the Club's constitution, club rules, code of conduct, disciplinary policy, equity policy, social networking and child welfare policy. I understand that if the above named member does not also abide by these rules / codes of conduct / policies that the club may take disciplinary action.