docClub Membership Form – Adults 2015
download 
Report Transcription
Club Membership Form – Adults 2015
B.M.O.H. Athletic Club 2015 Adult Membership Form We are very pleased to welcome you to B.M.O.H Athletic Club. To ensure that we have the correct contact details for you, please insert the information requested below. You must check and sign this application form before it is returned to the club. PERSONAL DETAILS Name: …………………………………………………………………………………. Address: ………………………………………………………………………………. ………………………………………………………………………………………….. Telephone: …………………………… Mobile: …………………………………… Emergency Contact (Name) ……………………………………………………….. Emergency Contact (Tel.) ………………………………………………………….. Email: …………………………………………………………………………………. Date of birth (dd/mm/yy): ………………………. Gender: M F Club Membership :Adult €50. 00 Juvenile €25 Student €35 Medical History and Consent Please provide details of any known allergies and medical conditions. e.g. epilepsy, asthma, diabetes, heart conditions etc ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ADDITIONAL INFORMATION Please also provide information on other issues that could affect your performance e.g. previous injuries, learning difficulties, visual or hearing impairments etc. ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… In the event of illness or accident, I give permission for medical treatment to be administered where considered necessary by a nominated first aider, or by suitably qualified medical practitioners. CLUB AGREEMENT By returning this completed form, I agree to participate responsibly in the activities of the club and understand that if I break any of the club’s codes of conduct, I may be subject to disciplinary action. I understand that in the event of any injury or illness, all reasonable steps will be taken to alert my emergency contact (where necessary), and I give permission for the club and/or any medical authorities present, to administer any appropriate or necessary medical attention. I understand that it is my responsibility to keep the club updated with all relevant information, especially emergency contacts and medical details. I consent to the club using appropriate images and photos (photography and video) for purposes relating to the promotion and marketing of the club and its activities: YES NO I consent to the club maintaining my records and information in confidential electronic documents and in club information folders, for the purpose of club administration. I understand that I have a right to see this information if I so desire, providing I give appropriate notice to the club. Name of participant: …………………………………………………………………… Signature of participant: ………………………………………………………………. Date (dd/mm/yy): ……………………………………….. Please return completed form together with payment and return to a club committee member. Application – Medical Screening Form This information is essential to ensure your safety and that you are assigned the appropriate level of exercise. Please answer all questions on this form (answer n/a where not applicable). Please do not leave blanks on the form. Personal Details Name: Email Address: Address: Mobile Number: Home Telephone: Date of Birth: GP Name: Gender: Occupation: Person to be contacted in case of emergency: Name: Contact number (s): Health and Medical History 1. Do you have or have you ever had any known heart condition? Yes No 2. Do you have any other medical conditions (e.g. Asthma, Diabetes, Arthritis, Gout, Epilepsy, Hernia, Dizziness, High Blood Pressure, Ulcer)? Yes No Yes No Yes No Yes No Please list or give brief details 3. Are you currently taking any medication? Please list or give brief details 4. Do you have any recent injuries that may be affected by exercise? Please list or give brief details 5. Do you currently have or in the recent past any back pain? 6. Do you have or have you ever had a bone or joint condition that could be made worse by exercise or that could prevent you from exercising? Yes No 7. Are you pregnant? Yes 8. Have you had a baby within the last year? Yes No No If yes, have you had your 6 week (or 10 week if relevant) post natal check-up? Yes No If yes, were you given the all clear to exercise? Yes No If you have not been cleared to exercise please consult your GP before engaging in a regular exercise programme. If you become pregnant at any time please inform your exercise leader. . Exercise History 9. Are you partaking in any form of exercise or physical activity at present? Yes No If yes, please give details of the type, frequency and duration of the exercise. If no, did you partake in any form of exercise or physical activity in the past? Yes No If yes how long has it been since you were engaged in regular exercise Informed Consent I confirm that I have completed the above questionnaire to the best of my ability and that I have provided accurate information regarding my current health status. I take it upon myself to discuss any changes in my health with the BMOH AC leaders/coaches. I understand that any exercise programme has certain risks. I understand that the degrees of risk depend on my health and physical fitness. I am voluntarily participating in the activities of this BMOH Athletic Club and I will immediately discontinue any activity if feeling any symptoms of distress or discomfort and I will notify a member of staff of same. In this respect, I hereby indemnify the club and leaders. Participant’s Signature: __________________________________________ BMOH AC Representative: _______________________________________ Date: ________________________ Date: ________________________
