New HMTBC Membership Application

Name of 1st Member *

First Name Surname

Date of Birth *

Day Month Year

Membership Number (if renewing)

Name of 2nd Member

First Name Surname

Date of Birth

Day Month Year

Membership Number (if renewing)

Additional Family Members Names and DOB

Address *

Street Address

Street Address Line 2

City County

Post Code Country

Telephone *

Area Code Phone Number

Mobile

Area Code Phone Number

E-mail *

If any applicants are British Cycling members please add membership numbers here

Annual Membership (ProRata until Mar 31st 2018 *

Adult over 16s £22 Junior under 16s £11 Adult + Junior £31 Couple (living at same address) £36 Family (2 adults, all children at same address) £48

Disability Information

The Disability Discrimination Act 1995 defines a disabled person as anyone with, ‘a physical or mental impairment, which has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities.’

Please indicate below if you consider yourself to have a disability?

If yes, what is the nature of your disability?

Do you consider yourself to have a disability?

Yes No

Nature of Disability

Medical Information

Please detail below any important medical information that our coaches/club should be aware of (e.g. epilepsy, asthma, diabetes, a recent injury, etc). Medical condition(s) and recommended treatment/actions to be taken if symptoms appear: If you have any concerns about your child participating in any form of physical activity then please consult your GP before giving permission for your child to take part in cycling activity sessions.

Medical Information

Contact in case of emergency *

First Name Last Name

Emergency contact number *

Area Code Phone Number

It is necessary to obtain consent for your child to take part in the Go-Ride activity. If you wish your son /daughter to participate then please read the following information, complete the form below and sign the Parental Consent Notice. All Coaches are trained British Cycling Coaches that have received training in Safeguarding and Protecting Children, and have been checked and cleared through the Criminal Records Bureau. Any information provided about your child will be kept confidential and secure. It will only be used for the purpose of contacting you or your child regarding future club and Go-Ride events. With your permission the club may also take photographs/video footage during Go-Ride activity. These images could be used in coaching resources, placed on the club’s website, or for general publicity purposes. If you are happy for photographs/video footage of your child to be taken and used in this way, could you please tick the appropriate box below.

By submitting this completed form, I agree to the child named above taking part in the activities of the club

I understand that I will be kept informed of these activities - for example timing and transport details

I understand that in the event of any injury or illness all reasonable steps will be taken to contact me, and to deal with that injury/illness appropriately

A cycling helmet must be worn at all time during activity.

Any participants who persistently misbehave or put others in danger will be asked to leave the activity and will not be allowed to continue.

Name of Parent / Carer

First Name Last Name

Consent

I am happy for photo/video footage to be taken of my child

Declaration *

I confirm that I have read and accept the terms on this form and the Hadleigh MTB Code of Conduct

Select Payment Amount *

Adult Membership ( £ 22.00 GBP for each year )

Youth Membership ( £ 11.00 GBP for each year )

1 Adult + 1 Youth Membership ( £ 31.00 GBP for each year )

Couple Membership ( £ 36.00 GBP for each year )

Family Membership ( £ 48.00 GBP for each year )

Total £ 0.00 GBP

Prove you are a human (or a very talented chimp) *

PLEASE READ: IMPORTANT INFORMATION ABOUT YOUR DATA!

When you become a member of or renew your membership with The Hadleigh MTB Club you will be registered for an online account with British Cycling. We will provide British Cycling with your personal data which they will use to enable access to an online portal for you (called My Dashboard) on the British Cycling website. British Cycling will use your personal data in accordance with its Privacy Notice which can be accessed at https://www.britishcycling.org.uk/staticcontent/info--Privacy-Policy-0. British Cycling will contact you to invite you to sign into and update your dashboard (which, amongst other things, allows you to set and amend your privacy settings). If you have any questions about the continuing privacy of your personal data when it is shared with British Cycling,
please contact compliance@britishcycling.org.uk.