Membership Application

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

Mobile Number

Email 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.

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