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\qc \li0\ri0\sl355\slmult0\nowidctlpar\tx1857\faauto\rin0\lin0\itap0\pararsid8262916 \fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\b\f2\fs34\insrsid3735589 Vale Royal Athletic Club
\par }\pard \qj \fi720\li720\ri0\sl364\slmult0\nowidctlpar\faauto\rin0\lin720\itap0\pararsid8262916 {\b\f2\fs34\insrsid3735589 \tab }{\b\f2\fs30\insrsid8262916 www. valeroyalathleticclub.co.uk
\par }\pard \qj \li0\ri0\sl355\slmult0\nowidctlpar\tx1632\faauto\rin0\lin0\itap0 {\b\f2\fs34\insrsid8402886 
\par }\pard \qc \li0\ri0\sl355\slmult0\nowidctlpar\tx1632\faauto\rin0\lin0\itap0\pararsid8262916 {\b\f2\fs34\insrsid3735589 MEMBERSHIP APPLICATION FORM
\par }\pard \qc \li0\ri0\sl355\slmult0\nowidctlpar\faauto\rin0\lin0\itap0\pararsid8262916 {\b\f2\insrsid8262916 (}{\b\f2\insrsid3735589\charrsid8262916 October 2004 to the end of September}{\b\f2\insrsid2043760\charrsid8262916  }{
\b\f2\insrsid3735589\charrsid8262916 2005}{\b\f2\insrsid8262916 )}{\b\f2\insrsid3735589\charrsid8262916 
\par }\pard \qj \li0\ri0\sl364\slmult0\nowidctlpar\faauto\rin0\lin0\itap0\pararsid8987005 {\b\f2\fs30\insrsid8987005 PART 1.
\par }{\b\f2\fs22\insrsid8987005\charrsid3958695 Vale Royal Athletic Club welcomes applications from all members of the community and will ensure all present and potential members receive fair and equal treatment.
\par Please complete all relevant information below and return this form }{\b\f2\fs22\insrsid3958695\charrsid3958695 with relevant membership fee }{\b\f2\fs22\insrsid8987005\charrsid3958695 to }{\b\f2\fs22\insrsid3958695\charrsid3958695 
Dave Stevens, Membership Secretary or any Club Official. The form may be posted to D.Stevens at 142 Runcorn Road, Barnton, Northwich, Cheshire, CW8 4HS. M}{\b\f2\fs22\insrsid3958695 embers under }{\b\f2\fs22\insrsid3958695\charrsid3958695 
age of 16 are required to gain a parental signature and}{\b\f2\fs22\insrsid8987005\charrsid3958695  }{\b\f2\fs22\insrsid3958695 complete Part 2 prior to returning the form.}{\b\f2\fs22\insrsid8987005\charrsid3958695 
\par }\pard \qj \li0\ri0\sl364\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\b\f2\fs30\insrsid3735589 
\par }\pard \qj \li0\ri0\sl182\slmult0\nowidctlpar\faauto\rin0\lin0\itap0\pararsid2043760 {\b\f2\fs22\insrsid3735589 TITLE}{\b\f2\fs22\insrsid2043760 ______}{\b\f2\fs22\insrsid3735589 FIRST NAME}{\b\f2\fs22\insrsid2043760  _______________\tab }{
\b\f2\fs22\insrsid3735589\charrsid2043760 SURNAME}{\b\f2\fs22\insrsid2043760  ________________________}{\b\f2\fs22\insrsid3735589\charrsid2043760 
\par }\pard \qj \li0\ri0\sl192\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\b\f2\fs22\insrsid3735589 
\par 
\par }\pard \qj \li0\ri0\sl182\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\b\f2\fs22\insrsid3735589 ADDRESS}{\b\f2\fs22\insrsid2043760  _______________________________________________________________}{\b\f2\fs22\insrsid3735589 
\par }{\b\f2\fs22\insrsid2043760 
\par ________________________________________}{\b\f2\fs22\insrsid13704547 _______________________________}{\b\f2\fs22\insrsid2043760 
\par }{\b\f2\fs22\insrsid3735589 
\par }\pard \qj \li0\ri0\sl192\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\b\f2\fs22\insrsid3735589 POSTCODE}{\b\f2\fs22\insrsid2043760 __________ }{\b\f2\fs22\insrsid13704547 MALE/FEMALE}{\b\f2\fs22\insrsid1995687 _________}{\b\f2\fs22\insrsid13704547 
   DATE OF BIRTH ________________
\par 
\par }{\b\f2\fs22\insrsid3735589 TELEPHONE No}{\b\f2\fs22\insrsid2043760  _______________}{\b\f2\fs22\insrsid13704547   }{\b\f2\fs22\insrsid2043760 MOBILE _______________}{\b\f2\fs22\insrsid13704547 ______}{\b\f2\fs22\insrsid1995687         }{
\b\f2\fs22\insrsid13704547 
\par 
\par }{\b\f2\fs22\insrsid1995687 E-}{\b\f2\fs22\insrsid3735589 MAIL ADDRESS}{\b\f2\fs22\insrsid2043760  __________________________}{\b\f2\fs22\insrsid3735589 
\par }{\b\f2\fs22\insrsid8402886 
\par }{\b\f2\fs28\insrsid8402886\charrsid8402886 MEDICAL INFORMATION}{\b\f2\fs28\insrsid8402886 
\par }\pard \qj \li0\ri0\sl192\slmult0\nowidctlpar\brdrb\brdrs\brdrw30\brsp20 \faauto\rin0\lin0\itap0 {\f2\fs22\insrsid8402886\charrsid8874959 Please detail below any important medical information that our coaches 
\par }\pard \qj \li0\ri0\sl192\slmult0\nowidctlpar\brdrb\brdrs\brdrw30\brsp20 \faauto\rin0\lin0\itap0\pararsid3735589 {\f2\fs22\insrsid8402886\charrsid8874959 should be aware of ( e.g. epilepsy, asthma, diabetes etc.)}{\f2\fs22\insrsid7485383 
\par }{\f2\fs22\insrsid11932637 
\par }\pard \qj \li0\ri0\sl192\slmult0\nowidctlpar\faauto\rin0\lin0\itap0\pararsid3735589 {\fs26\insrsid11932637 __________________________________________________________________________}{\fs26\insrsid3735589 
\par }\pard \ql \li0\ri0\sl220\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\b\f2\fs28\insrsid13897134 
\par }{\b\f2\fs28\insrsid11932637 Disability: }{\b\f2\fs28\insrsid13897134 
\par }{\f2\fs22\insrsid11932637\charrsid11932637 Do you consider yourself}{\f2\fs22\insrsid11932637  to have a disability :}{\f2\fs22\insrsid13897134  }{\f2\fs22\insrsid11932637 YES}{\f2\fs22\insrsid13897134  }{\f2\fs22\insrsid11932637 ___}{
\f2\fs22\insrsid13897134    }{\f2\fs22\insrsid11932637 NO}{\f2\fs22\insrsid13897134 _}{\f2\fs22\insrsid11932637 __
\par If yes, what is the nature of your disability (eg visually impaired, hearing impaired, physical disability, learning disability, multiple disability):_____________________________________________________________
\par }{\f2\fs22\insrsid1995687 
\par }{\f2\fs22\insrsid11932637 _________________________________________________________________________ }{\f2\fs22\insrsid3735589\charrsid11932637 
\par }{\b\f2\fs22\insrsid11932637\charrsid11932637 
\par }{\b\f2\fs28\insrsid7485383\charrsid7485383 EMERGENCY CONTACT DETAILS}{\b\f2\fs28\insrsid7485383 
\par }{\f2\fs22\insrsid7485383 Please insert the information below to indicate the person(s) who should be contacted in case of incident/accident.
\par 
\par Contact name:________________ Emergency Contact Number_________________ 
\par }{\b\f2\fs28\insrsid10961351\charrsid10961351 PART 2.}{\b\f2\fs28\insrsid7485383\charrsid10961351 
\par }{\b\f2\insrsid10961351\charrsid10961351 PARENTAL CONSENT TO BE COMPLETED FOR MEMBERS UNDER 16 YEARS OF AGE
\par }{\f2\fs22\insrsid10961351\charrsid10961351 By returning this completed form I agree to the child in my care taking part in the activities of the club.
\par Vale Royal AC }{\f2\fs22\insrsid10961351 
recognises the need to ensure the welfare and safety of all young people in sport. In accordance with our child protection policy we will not permit photographs, video or other images of young people to be taken without the consent of the par
ents/carers and children.
\par Vale Royal AC will follow the AAAE Welfare }{\f2\fs22\insrsid8262916 P}{\f2\fs22\insrsid10961351 olicy }{\f2\fs22\insrsid8262916 
guidance for the use of photographs and will take all steps to ensure these images are used solely for the purposes they are intended.}{\f2\fs22\insrsid12609318  If you become aware that these images are bei
ng used inappropriately you should inform a club official immediately.
\par I consent to Vale Royal AC photographing or videoing ______________(name of child)
\par I ______________ (name of child) consent to Vale Royal AC photographing or videoing my involvement in athletics.
\par 
\par Name of parent/guardian: __________________________
\par 
\par Signature of parent/guardian:_______________________ Date: _____________ }{\f2\fs22\insrsid10961351\charrsid10961351  
\par }{\b\f2\fs28\insrsid10961351 
\par }{\b\f2\fs28\insrsid12609318 PART 3.
\par SPORTING INFORMATION
\par }{\f2\fs22\insrsid12609318 Have you taken part in athletics before ? YES____ NO ___
\par }{\f2\fs22\insrsid8152850 If yes, please indicate below where.}{\f2\fs22\insrsid12609318 
\par }{\f2\fs22\insrsid8152850 Primary school ____ Secondary school____ Club__________ Other___________
\par }{\f2\fs22\insrsid8152850\charrsid12609318 
\par }\pard \qj \li0\ri0\sl220\slmult0\nowidctlpar\tqc\tx4425\faauto\rin0\lin0\itap0 {\f2\fs22\insrsid3735589 Disciplines in which you expect to participate(Please Circle)
\par }{\f2\fs22\insrsid1995687 
\par }{\f2\fs22\insrsid8152850 Road Running/Track & Field/Cross }{\f2\fs22\insrsid3735589 Country}{\f2\fs22\insrsid8152850 /Hill&Fell }{\f2\fs22\insrsid3735589 Run}{\f2\fs22\insrsid8152850 ning/}{\f2\fs22\insrsid3735589 Race Walking.
\par 
\par }\pard \qj \li0\ri0\sl254\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\f2\fs22\insrsid3735589 Do you hold any Coaching Qualifications?}{\f2\fs22\insrsid8152850  YES/NO}{\f2\fs22\insrsid3735589 
\par }{\f2\fs22\insrsid8152850 If yes, please detail:______________________________}{\f2\fs22\insrsid3735589 
\par }{\f2\fs22\insrsid8152850 
\par }{\f2\fs22\insrsid8152850\charrsid8152850 ****************************************************************}{\b\f2\fs22\insrsid8152850\charrsid8152850 
\par }\pard \qj \li0\ri0\sl172\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\b\f2\fs22\insrsid3735589 MEMBERS OF OTHER ATHLETIC CLU}{\b\f2\fs22\insrsid4079025 BS ONLY TO COMPLETE THIS SECTION}{\b\f2\fs22\insrsid3735589 
\par }\pard \ql \li0\ri0\sl235\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\f2\fs22\insrsid3735589 Your other Clubs name}{\f2\fs22\insrsid4079025 : _________________________}{\f2\fs22\insrsid3735589 
\par Do you intend to resign from the above Club? YES / NO }{\f2\fs22\insrsid4079025 
\par }{\f2\fs22\insrsid3735589 Date of Resignation}{\f2\fs22\insrsid4079025 :___________}{\f2\fs22\insrsid3735589 
\par }{\f2\fs22\insrsid4079025 Do you intend }{\f2\fs22\insrsid3735589 to jo}{\f2\fs22\insrsid4079025 in VRAC as }{\f2\fs22\insrsid3735589  Second Claim? YES / NO
\par }\pard \ql \li0\ri0\sl316\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\b\fs28\insrsid3735589 *************************************************************
\par }\pard \qj \li0\ri0\sl201\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\b\f2\fs20\insrsid3735589\charrsid3735589 TO BE COMPLETED BY ALL APPLICANTS:}{\b\f2\fs20\insrsid3735589\charrsid13897134 
\par }\pard \ql \li0\ri0\sl187\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\f2\fs18\insrsid4079025 I confirm that I }{\f2\fs18\insrsid3735589 am eligible to compete under UKA Rules.
\par I accept*/do not accept* that my personal data will be held on computer database by the Club. I agree*/Bo not agree* to the disclosure of my personal data in a list of members to the North of England AA.
\par (Please delete as applicable*).
\par 
\par }\pard \ql \li0\ri0\sl264\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\b\f2\fs22\insrsid3735589 SIGNED}{\b\f2\fs22\insrsid8402886  _________________}{\b\f2\fs22\insrsid3735589  DATE}{\b\f2\fs22\insrsid8402886  ____________________}{
\b\f2\fs22\insrsid3735589 
\par }\pard \ql \li0\ri0\sl302\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\f2\fs22\insrsid8402886  }{\f2\fs22\insrsid3735589 (Signature of parent or guardian if under }{\f2\fs22\ul\insrsid3735589 16)
\par }\pard \ql \li0\ri0\sl220\slmult0\nowidctlpar\faauto\rin0\lin0\itap0\pararsid13897134 {\b\f2\fs28\insrsid13897134 *********************************************************}{\b\f2\fs28\insrsid13897134\charrsid7485383 
\par }\pard \qj \li0\ri0\sl254\slmult0\nowidctlpar\tx2798\faauto\rin0\lin0\itap0\pararsid13897134 {\b\f2\fs32\insrsid13897134 Membership Fees
\par }\pard \qj \li0\ri0\sl244\slmult0\nowidctlpar\faauto\rin0\lin0\itap0\pararsid1995687 {\b\f2\fs22\insrsid13897134 SENIORS \'a330-00, JUNIORS/STUDENTS \'a320-00, FAMILY \'a360-00 }{\b\fs18\insrsid13897134 AND }{\b\f2\fs22\insrsid13897134 COACHES \'a315-00. 
}{\b\f2\fs22\ul\insrsid13897134 Cheques payable to Vale Royal Athletic Club}{\b\f2\fs22\ul\insrsid3735589\charrsid1995687 
\par }}