Name* First Last Type of Application Affiliated Member (First Claim) Affiliated Member (Second Claim) Non Affiliated Member Are you already a member of England Athletics? If so, please enter your URN: Address* Address Line 1 Address Line 2 Address Line 3 Postcode Date of Birth YYYY slash MM slash DD Mobile NumberEmail Address* Emergency Contact Name* First Last Emergency Contact Number*I understand that if I wish to become an affiliated runner, a fee of £15.00 is payable annually directly to England Athletics, plus £1.00 administration fee (total = £16.00) Yes Broseley Joggers wish to remain a free club for as long as is possible. To this end, we have included our bank details should anyone wish to make a voluntary contribution to the continued running of the club, purchase of equipment and the training of new run leaders. (To be paid electronically into the Broseley Joggers Account. Details : Sort Code: 30-18-55 Account No: 58535360. Please use your name as the reference. If this is not possible, please contact the Treasurer at broseleyjoggers@hotmail.com to discuss an alternative.Declaration* I agree to the following:I agree to abide by Broseley Joggers Club rules (a copy should be attached but can also be found at http://broseleyjoggers.org). I confirm that I understand that participation is entirely at my own risk and I should consult with my own doctor if suffering from any condition that might make running injurious to my health. I acknowledge that the club bears no responsibility for accident, illness, loss or damage as a result of my membership. I agree to photographs being taken and used on Broseley Joggers website or social media sites. I have received and understood Broseley Joggers GDPR statement, signed and returned a copy.