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Membership Form 2020 – 21 Season

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Membership Form 2020 – 21 Season SOUTHPORT WATERLOO AC (Affiliated to England Athletics and UKA) President: Steve James SOCIAL MEMBERSHIP FORM 2020 – 21 SEASON Dear Applicant, Thank you for looking to join Southport Waterloo A.C. as a Social member. Joining as a Social member means that you can feel part of the club as a direct member. We are very pleased that you will be joining us as a coach, official or volunteer. This form of membership also entitles you to a vote at the Clubs’ AGM that is held in November of each year, details are advertised on the club website at least two weeks before. Please fill out the details in this form and send it along with the £12.00 Social membership fee to our membership secretary at the address on the back of this form. About you: FIRST NAME: SURNAME: D.O.B. GENDER M/F ADDRESS: TOWN/CITY: COUNTY: POSTCODE: HOME MOBILE TELEPHONE: NUMBER: EMAIL: Do you use Social Media: FACEBOOK: TWITTER: INSTAGRAM: OTHER: Emergency Contact: NAME: HOME NUMBER: MOBILE NUMBER: RELATIONSHIP TO YOU: What kind of volunteering, if any, would you be able to offer? Coach or Time keeper Field Judge Team Manager General help at Assistant coach track events Marshall Race Director General Committee Other (specify) at races help at club Member events Do you already have a qualification(s): Type: Level: Licence No: Expiry date: Website: www.sw-ac.co.uk Other information about you: Do you consider yourself to have a disability*: (Please indicate the nature of that disability, hearing, learning, multiple, physical or visual.) Other medical information*: (Please detail any important medical issues we should be aware of.) *Please note all information is treated with full confidentiality. Membership is open to all groups in the community. In order to help us monitor our membership, please select your ethnic origin from the list below: White British Black Carribean White & Black Asian Indian Chinese Carribean White Irish Black African White & Black Asian Pakistani Asian other African White other Black Other White & Asian Asian Other Bangladeshi Photographic consent: I do not wish my picture to be used on the Club Website: I do not wish for my picture to be used on Club promotional material: I do not wish for my picture to be used on other athletic Websites (e.g. Merseyside AAA): We will take all steps to ensure that images are used only for the intended purpose. Application Declaration: • I wish to become a Social member of Southport Waterloo A.C. • I confirm that I understand a DBS may be required under British Athletics regulations. • I understand that my personal data will be held by the club on a computer and will be disclosed to England Athletics for registration purposes. Signature: Dated: Southport Waterloo A.C. recognizes the need to ensure the welfare and safety of all young people in sport. We do have a Child protection policy in place, copies are available on the club website: www.southportwaterlooac.co.uk If as a coach or volunteer, you have any concerns then please do not hesitate to contact one of our Child Protection officers immediately. Gill Gillison (Southport) on 01704-228380. The information provided by you will be treated with the greatest amount of confidentiality and respect. Now that you have filled in the membership Barrie Hughes application, please pass or post it to the Clubs’ 24 Edgemoor Drive Membership Secretary at the address provided. Crosby Please make your cheque payable to: Liverpool Southport Waterloo A.C. L23 9UG To pay by standing order, please speak to the Tel: 07931-606-244. Membership Secretary about this option. Email: [email protected] Honorary Secretary: Chairman: Honorary Treasurer: CHRISTOPHER HENDERS KEITH LUNT Su Hughes 10 Holden Grove 7 Cheriton Park 24 Edgemoor Drive Brighton-le-Sands Southport Crosby Liverpool Merseyside Liverpool L22 6QJ PR8 6QB L23 9UG Tel: 07940-333-040 Tel: 01704 510882 Tel: 07788-782-129 Email: [email protected] Email: [email protected] Email: [email protected] Website: www.sw-ac.co.uk .
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