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Tipton Harriers Membership Form 2021/22
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* Indicates required question
Mr/Mrs/Ms/Miss
*
Salutation
Mr
Mrs
Ms
Miss
Other:
First Name
*
Your answer
Surname
*
Your answer
Address Line 1
*
Your answer
Address Line 2
*
Your answer
Address Line 3
Your answer
Address Line 4
Your answer
Post Code
*
Your answer
Phone Number
Your answer
Email Address
*
Your answer
Town and Country of Birth
*
Your answer
Date of Birth (DD/MM/YYYY)
*
Your answer
Coach
Your answer
School
Your answer
Event / Role
*
In what way are you involved with the club? Tick all that apply
Track & Field Athlete
Endurance Athlete (Non Track)
Coach
Official (Time Keeper, Track / Field Judge etc)
Volunteer
Life Member
Other:
Required
Do You Consider Yourself To Have a Disability?
*
Yes
No
If "Yes" Please Give Details and Competition Category
Your answer
Emergency Contact Name
Your answer
Emergency Contact Phone Number
Your answer
Emergency Contact Relationship To Athlete
Your answer
Name of Person For Permission For Travel and Medical Treatment
Your answer
Please indicate that you agree to abide by the rules of the club
*
I Agree
Required
Where athlete is under 18 years of age please state consenting adults name
Your answer
Membership Rates For 2020/21
The rates below are full rate with the reduced rate in brackets - the reduced rate is ONLY for members paid last year
Select Membership Rate
*
£115 (£80) Adult 18 and Over (Including Track Fees)
£80 (£56) Adult 18 and Over (Not Including Track Fees)
£105 (£73) Student (Age 11 to 18)
£95 (£66) Under (Age Under 11)
£230 (£160) Family (2 Adults + at least 1 child up to 18)
£35 2nd Claim (£4 per week for ad-hoc track use)
£0 Coach
£20 Competing Coach (Qualified and actively coaching at Tipton)
£0 Life Member
Payment Options
*
Bank Transfer (Sort 05-04-21 A/C 46593527) Please use your name as a reference. Due to the club's status as a not for profit organisation the payment should be set up as an individual - not a company.
No Payment (eg Life Member, Non-competing Coach, Volunteer)
Name and Date of Birth of Additional Family Member
Your answer
Name and Date of Birth of Additional Family Member
Your answer
Name and Date of Birth of Additional Family Member
Your answer
Name and Date of Birth of Additional Family Member
Your answer
Any Queries?
Please contact the Membership Secretary Bryan Mills, or ask at the Tipton Harriers reception desk. email
membership@tiptonharriers.co.uk
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