KIMBERWORTH STRIDERS RUNNING CLUB est 1986 2018/19 MEMBERSHIP APPLICATION FORM FULL NAME ADDRESS INC POST CODE DATE OF BIRTH PHONE EMAIL ARE YOU A CURRENT MEMBER OF ANOTHER UKA CLUB? (IF YES YOU CAN TRANSFER YOUR MEMBERHSIP TO KIMBERWORTH OR JOIN US AS SECOND CLAIM – PLEASE STATE) CURRENT CLUB NAME (IF APPLICABLE) EXISTING UKA MEMBERSHIP NO. (IF APPLICABLE) When you become a member of or renew your membership with Kimberworth Striders you will automatically be registered as a member of England Athletics. We will provide England Athletics with your personal data which they will use to enable access to an online portal for you (called myAthletics). England Athletics will contact you to invite you to sign into and update your MyAthletics portal (which, amongst other things, allows you to set and amend your privacy settings). If you have any questions about the continuing privacy of your personal data when it is shared with England Athletics, please contact [email protected] I wish to apply for membership of Kimberworth Striders Running Club and hereby agree to abide by the rules set out in the club’s constitution and the passing of my details to England Athletics. I declare that I am medically fit to take part in running and that the club shall not be liable for accident, injury or damage as a consequence of my membership in Kimberworth Striders Running Club. SIGNED: ………………………………………………………….. DATE: …………………………………………………………………… Membership is effective from 1st April 2018 to 31st March 2019, inclusive. 1st claim fee - £25 (over 70’s free) 2nd claim/Social Member (delete as applicable) fee - £5 (over 70’s free) Please send this completed form, with membership fee (cheques payable to ‘Kimberworth Striders’) to Chris Lilley at the address below: 47 Grange Road, Rotherham, South Yorkshire, S60 3LH Website: www.kimberworthstriders.co.uk Email:[email protected] .