Membership Form 2017

Membership for Togher AC for the year 2017 is due by 31st December 2016. Please note that any athlete who has not paid membership by this date will not be covered under the clubs insurance policy and will not be entered into any competition.

Please read carefully and complete all sections.

If you wish to pay electronically for membership, please complete the form below.If you would prefer to pay by cash/cheque, please download and complete a word version membership formHERE.

Membership Type: (Please tick) *

Note: Little Athletics has a wait list for children born after 2007. For children born prior to 2007, there is no waiting list.To enquire regarding Little Athleticsor to be put on the waiting list, please contact Aidan Hartnett on 087 643 6897 or aidan.hartnett@hotmail.com.

Family Rate - must include at least one Little Athletic or Juvenile/Junior athlete.

Name1:*
Male/Female1:*
DOB1:*
 / 
 / 
Birth County1: (e.g. Cork)*
Address: (of parent/guardian where applicable) include postal code*
Email: (of parent/guardian where applicable) *
Any Medical Conditions / Allergies / Disabilities1:*
Phone Number: (of Parent/Guardian where applicable)*
-
Contact Name & Phone Number in case of Emergency:*

Photographs:Parents/guardians should be advised that the club or event that their child is attending may record and/or take photographs for the promotion of the sport within the club, county, province or national event.

Parents, please consult with your child on this issue.

1. Declaration: I understand that appropriate photographs and video footage may be taken during, or at Togher Athletics Club related events and may be used in the promotion of the club. I hereby consent to use of the above. Please tick the relevant box:*
Please note that all other events are subject to Athletics Ireland guidelines

I the undersigned have read and agree to abide by the rules of the club as set out by the committee for 2017.

Electronic Signature: (Note: where the athlete is a minor the parent/guardian must sign)*
Word Verification:

___________________________________________________________________________

Please complete details for additional family members here:

Name2:
Male/Female2:
DOB2:
 / 
 / 
Birth County2:
Any Medical Conditions / Allergies / Disabilities2:
2. Declaration I understand that appropriate photographs and video footage may be taken during, or at Togher Athletics Club related events and may be used in the promotion of the club. I hereby consent to use of the above. Please tick the relevant box:

___________________________________________________________________________

Name3:
Male/Female3:
DOB3:
 / 
 / 
Birth County3:
Any Medical Conditions / Allergies / Disabilities3:
3. Declaration I understand that appropriate photographs and video footage may be taken during, or at Togher Athletics Club related events and may be used in the promotion of the club. I hereby consent to use of the above. Please tick the relevant box:

___________________________________________________________________________

Name4:
Male/Female4:
DOB4:
 / 
 / 
Birth County4:
Any Medical Conditions / Allergies / Disabilities4:
4. Declaration I understand that appropriate photographs and video footage may be taken during, or at Togher Athletics Club related events and may be used in the promotion of the club. I hereby consent to use of the above. Please tick the relevant box:

___________________________________________________________________________

Name5:
Male/Female5:
DOB5:
 / 
 / 
Birth County5:
Any Medical Conditions / Allergies / Disabilities5:
5. Declaration I understand that appropriate photographs and video footage may be taken during, or at Togher Athletics Club related events and may be used in the promotion of the club. I hereby consent to use of the above. Please tick the relevant box: