Membership Form 2015 - pdf

MEMBERSHIP FORM April 2015 - March 2016
Please read the 'Notes and conditions' overleaf before filling in this form.
To be completed by a committee member
Form accepted by:
Paid:
NEW MEMBER
Cash : ☐
£
☐
RENEWING MEMBER
Cheque: ☐
☐
BACS: ☐
MEMBER SINCE:
Type of Membership:
Apr-Mar (full year)
Oct-Mar (half year)
Adult:
☐ £60
☐ £30
Under 18:
☐ £40
☐ £20
Instructor:
☐ £30
☐ £15
Extra family member & boats
Full year (½ price)
Half year ( ½ price)
Number of Adults
Number of Children (<18years old)
Number of boats stored (per form)
@£20 per boat
@£10 per boat
Total payable - maximum £100 per family, plus boat storage
Full Name
Date of Birth
Address
E-mail
Phone Number :
Home
Mobile
Emergency Contact:
Name
Phone number
Allergies / disabilities / medication - If you have none put ‘NONE’
BCU number (if applicable)
BCU qualifications(if applicable)
Please list details of any boats stored below (maximum of 2 boats per member or 4 per family):
Boat Make/Model:
Colour:
Over 4m ☐ Canoe ☐
Over 4m ☐ Canoe ☐
Over 4m ☐ Canoe ☐
Over 4m ☐ Canoe ☐
We'd appreciate it if you wrote your name on any boats stored. We can provide boat cards for this.
Membership year: April 2015 – March 2016
This section is for extra family members. If more space is required use another form and attach it to this one:
Name
Name
Date of Birth
Date of Birth
BCU number
BCU number
BCU qualifications
BCU qualifications
Allergies / disabilities
/ medication
Allergies / disabilities
/ medication
Name
Name
Date of Birth
Date of Birth
BCU number
BCU number
BCU qualifications
BCU qualifications
Allergies / disabilities
/ medication
Allergies / disabilities
/ medication
I have read and accept the 'Notes and conditions':
☐
I confirm that all those indicated on this form can swim at least 50m:
☐
If you do not want to be contacted via email by ACC please check the box: ☐
Signed:
Date:
Member ☐
Parent/Guardian ☐
We will accept the form if you type in your name when completing electronically
Payment Options:
1. Cheques should be made payable to 'ADUR CANOE CLUB'. Send your completed form and cheque to Membership
Secretary, Adur Canoe Club, AOAC, Brighton Road, Shoreham-by-Sea, BN43 5LT
2. Cheques or cash can be given to a committee member at the Adur Canoe Club sessions
3. BACS - If you would like to pay by BACS:
a. Account name: Adur Canoe Club, Sort code: 309874, Account Number: 03078250
b. Email the completed form to [email protected]
c. Please include details of the payee’s name, the amount paid, and the date the money was transferred in the
email. (Without this we will not be able to process your application form).
Notes and Conditions:
1. Canoeing is a sport with an element of danger. All persons attending Club activities do so at their own risk and neither
the Club nor its officers can accept any liability for loss or injury of any kind. We do not provide you with personal
accident insurance.
2. We generally cannot accept unaccompanied children under 12 on the river. If your under-12 wishes to paddle, please
be prepared to stay around during the session.
3. Canoeing activities are weather dependent and we rely on voluntary instructors attending. If you leave a child with
us, please check before you go that we are able to accommodate them or they have the means to safely return
home early.
4. Boats and kit stored at the Adur Centre are not insured by the Club or by the Adur Centre Trust.
5. Please ensure you read and are familiar with the Club Rules (on the website and notice board at the Adur Centre).
6. By signing this form you agree to have your details entered onto the membership database. This information will be
treated as confidential and will not be disclosed to any third parties.
7. Adur Canoe Club is run by volunteers and as such it is expected that each member assists in the daily running of the
club and activities.
Membership year: April 2015 – March 2016