WABC - Membership Form 2020/2021

Members Details

Forename (s)*

Surname*

Address (Line 1)*

Address (Line 2)*

Post Code*

Date of Birth*

Date

Age (years)*

School/College/University*

Emai Address*

Contact Number*

Emergency Contact

Name*

Relationship*

Contact Number*

Exercise Readiness Questionnaire

Have you ever been advised by your GP/Doctor, not to undertake exercise?*

NOYES

Do you have a bone or joint problem that could worsen by undertaking exercise?*

NOYES

Do you suffer from spells of dizziness or feeling feint?*

NOYES

Do you ever get chest pains, caused by exercise or high intensity tasks (i.e. cleaning) ?*

NOYES

Have you ever had high blood pressure?*

NOYES

Are you currently taking any medication?*

NOYES

Are you pregnant, or have had a baby in the last 6 months?*

NOYES

Is there any other information, reason or cause which may affect you whilst exercising?*

NOYES

Any other information (Include medication, injuries, surgery etc - please write CLEARLY)

MEDIA: I would like to be included in media for club promotional purposes - including, but not limited to photography, video, audio or print. I understand that from time to time the club will give the rights to third parties for editorial and broadcasting purposes (this applies to all media).*

NOYES

Member Declaration:

I agree to abide by the ‘Rules and Club Values 2020 - 2021’

The information I/we have provided is true and accurate to the best of my knowledge.

All participants under the age of 18 years must obtain parental/adult consent prior to participation.

I understand my membership is valid from 1 August 2020 until 31 July 2021

DECLARATION - Member*

DECLARATION - Parent/Guardian (for members under 18 years of Age)

DATE:*

Date