<p> PUDSEY PACERS RUNNING CLUB </p><p>Based at Pudsey Leisure Centre Market Place Pudsey</p><p>MEMBERSHIP APPLICATION/SUBSCRIPTION FORM 2015</p><p>Please complete details in BLOCK CAPITALS</p><p>Title _____ First Name ______Last Name ______</p><p>New Member Existing Member Date of Birth Male/Female</p><p>Address Postcode</p><p>Nationality: UK Athletics No.</p><p>Your home number Your mobile number</p><p>E-mail addresses</p><p>Emergency contact details Name Relationship Home number Mobile number</p><p>Disciplines in which you expect to participate Road running Cross country Fell/hill running Trail Running </p><p>Details of any qualifications or other experience – eg coaching, first aid, health & safety, IT skills, marketing, accounting… you may have which can assist the club Detail(s Occupation )</p><p>Are you joining Pudsey Pacers as your main (1st claim) club or as 2nd claim?</p><p>I confirm that I am eligible to compete under UK Athletics Rule. I accept that my personal data will be held on a computer by the club. I agree to the disclosure of my personal data to England Athletics. I understand that the club will not be held responsible for any personal risk, injuries or loss, incurred as a result of the club’s activities. </p><p>Do you have any health considerations we ought to know about Yes/No? If Yes, please ask for our Health Questionnaire.</p><p>I confirm that I understand that participation in the clubs activities is entirely at my own risk and should consult my own doctor if suffering from any condition that might make such activities injurious to my health.</p><p>Signed Date (Parent or Guardian if under 18, minimum age 17)</p><p>I enclose subscription* payment of £______cheque/cash (cheques payable to “Pudsey Pacers Running Club”) *Note: Annual subscription costs £30, but discounts are available, please contact Club Treasurer or Secretary.</p><p>New Members Only Reason for joining Pudsey Pacers How did you find out about the club? Last 5k / 10k time (if completed recently)</p><p> www.PudseyPacers.com I would like to purchase a club vest (circle size) F34 F36 F38 F40 M38 M40 M42 M44 M46 Other – please ask</p><p> www.PudseyPacers.com</p>